Tissue Doppler imaging in the evaluation of left ventricular diastolic function

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

Do we have two hearts? New insights in right ventricular function supported by myocardial imaging echocardiography

RV performance is difficult to evaluate, given its geometry, interrelationship with the left ventricle, and sensitivity to alterations in pulmonary pressure. This article focuses on some of the challenges related to the assessment of RV function in the setting of the RV’s unique anatomic, physiologic, conventional and newer echocardiographic aspects, and therapeutic implications. The majority of proposed methods of echocardiographic assessment of RV function are based on volumetric approximations of the RV. Such approaches have inherent limitations, first as volume-related measures such as EF are load dependent, second because of the complex geometry of the RV. The issue of RV geometry is usually overcome using geometry-independent parameters such as tricuspid annular excursion and the Tei index. The recent introduction of real-time three-dimensional echocardiography and myocardial imaging echocardiography (tissue Doppler imaging, 1D-strain and 2D-strain echocardiography) implied a great progress in echocardiography. Tissue Doppler imaging allows the quantitative assessment of RV systolic and diastolic function by means of measurement of myocardial velocities. Strain measurements have been shown to correlate well with sonomicrometry segment length measurements both in the inflow and outflow tract of the RV and under different loading conditions. Other findings have been reported in chronic and acute clinical settings. Standard and novel echocardiographic methods of assessment of RV size and performance can help clinicians in the treatment of acute and chronic RV failure and contribute to a better understanding of the peculiar chamber-related functional mechanisms in the context of ventricular interdependent independency.     

Cardiovascular Complications in Acromegaly: Methods of Assessment

Cardiac involvement is common in acromegaly. Evidence for cardiac hypertrophy, dilation and diastolic filling abnormalities has been widely reported in literature. Generally, ventricular hypertrophy is revealed by echocardiography but early data referred increased cardiac size by standard X-ray. Besides, echocardiography investigates cardiac function and value disease. There are new technologic advances in ultrasonic imaging. Pulsed Tissue Doppler is a new non-invasive ultrasound tool which extends Doppler applications beyond the analysis of intra-cardiac flow velocities until the quantitative assessment of the regional myocardial left ventricular wall motion, measuring directly velocities and time intervals of myocardium. The radionuclide techniques permit to study better the cardiac performance. In fact, diastolic as well as systolic function can be assessed at rest and at peak exercise by equilibrium radionuclide angiography. This method has a main advantage of providing direct evaluation of ventricular function, being operator independent. Coronary artery disease has been poorly studied mainly because of the necessity to perform invasive procedures. Only a few cases have been reported with heart failure study by coronarography and having alterations of perfusion which ameliorated after somatostatin analog treatment. More recently, a few data have been presented using perfusional scintigraphy in acromegaly, even if coronary artery disease does not seem very frequent in acromegaly. Doppler analysis of carotid arteries can be also performed to investigate atherosclerosis: however, patients with active acromegaly have endothelial dysfunction more than clear-cut atherosclerotic plaques. In conclusion, careful assessments of cardiac function, morphology and activity need in patients with acromegaly.     

Newer Imaging Modalities in the Assessment of Heart Function in Single Ventricle Hearts

The limitations of geometry assumptions in 2-dimensional echocardiographic assessment of the single ventricle (SV) have been overcome by recent advances in 3-D echocardiography. Improved reproducibility for measuring ventricular volumes and ejection fraction using 3-D echocardiography makes it ideally suited for serial monitoring of SV systolic function and should be considered in routine echocardiography imaging protocols for SV. The moderate correlation of Doppler derived E/e' ratio with invasive ventricular end diastolic pressure in SV, suggests it might be useful in the assessment of SV diastolic function. Speckle tracking imaging is intensely studied and promises to be a simple and repeatable imaging tool for quantifying SV function. In contrast, the advances in cardiac magnetic resonance imaging techniques promise to offer insights into the pathogenesis of myocardial dysfunction in SV. Late gadolinium enhancement imaging is a robust tool in assessing macroscopic myocardial scarring and T₁ mapping and stress perfusion imaging are newer modalities that might improve understanding of the mechanisms in progressive myocardial dysfunction in SV hearts.     

Role of echocardiography in the diagnostic assessment and etiology of heart failure in the elderly--opacify, quantify, and rectify

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance; estimate the cardiac output, pulmonary artery, and ventricular filling pressures; and identify surgically correctable valve disease. Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pacemaker leads.     

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.     

Comparison of left ventricular function by tissue Doppler imaging in patients with diabetes mellitus without systemic hypertension versus diabetes mellitus with systemic hypertension

Because diabetes mellitus substantially increases the risk of development of heart failure, we sought to establish early alterations in left ventricular systolic and diastolic function in patients with diabetes mellitus with and without coexisting systemic hypertension. We studied 134 subjects using echocardiography comprising standard 2-dimensional and conventional Doppler as well as tissue Doppler imaging. Our study demonstrated the early appearance of both left ventricular systolic and diastolic dysfunction in diabetic patients at rest and the contributory effects of diabetes to myocardial impairment produced by hypertension, as well as the high usefulness of tissue Doppler imaging in detection and quantitation of myocardial dysfunction in diabetics. This method was superior to other echocardiographic techniques and plasma brain natriuretic peptide evaluation.     

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.     

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.     

Role of echocardiography in the diagnostic assessment and etiology of heart failure in the elderly--opacify, quantify, and rectify

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance;estimate the cardiac output, pulmonary artery, and ventricular fill-ing pressures; and identify surgically correctable valve disease.Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pace-maker leads.     

Doppler echocardiographic-guided diagnosis and therapy of heart failure

Abnormalities of diastolic function play a major role in producing the signs and symptoms of heart failure. In patients with heart failure and reduced left ventricular systolic function, concomitant diastolic dysfunction is invariably present. In addition, it is now well established that as many as 40% to 50% of patients with well-documented episodes of heart failure have preserved systolic function. Doppler echocardiography provides one of the most useful clinical tools for assessing left ventricular diastolic function and can provide diagnostic and prognostic information. The Doppler assessment of diastolic function should be part of the routine echocardiographic evaluation of patients suspected of having heart failure. This review focuses on the use of Doppler echocardiographic techniques to assess diastolic function. The Doppler patterns of diastolic filling observed and their progression over time in patients with myocardial disease are described and related to changes in the physiology of diastolic filling. In addition, Doppler echocardiographic-guided treatment strategies for heart failure are discussed.     

In vivo Echocardiographic Assessment of Left Ventricular Function in Transgenic and Gene-Targeted Mice

Manipulation of the mammalian genome with transgenic and gene-targeting techniques is a powerful method for unambiguously identifying the molecular mechanisms underlying cardiac development and function. Although the small size of the mouse heart and the rapid heart rates encountered have limited echocardiographic assessment of the murine heart in the past, the use of sophisticated transducers operating at a high frequency results in highly reliable and reproducible image quality. M-mode echocardiography has been shown to provide a good correlation with gravimetrically determined left ventricular mass (LV) and to estimate accurately LV dimensions and systolic function. Doppler interrogation of transvalvular flows permits assessment of global LV systolic and diastolic function independent of ventricular geometry. Linear stress-shortening relations can be determined in the adult mouse with the use of pharmacologically induced changes in systemic arterial pressure, and these relations are capable of detecting changes in myocardial contractility in vivo, relatively independent of loading conditions. The present review focuses on the current advantages and limitations of M-mode and Doppler echocardiography to evaluate cardiac function in mice. (Trends Cardiovasc Med 1997;7:129-134). ? 1997, Elsevier Science Inc.     

Tissue Doppler imaging: clinical topics for the new millenium.

INTRODUCTION: Tissue Doppler imaging is an echocardiographic technique that allows the selective visualization and quantification of myocardial signals. Its aim is to complement the conventional Doppler study, adding more and better information on specific topics of cardiovascular diseases. During the first seven years of the technique, much scientific work was produced and some clinical applications of the method have emerged. CLINICAL APPLICATIONS: I--non ischemic heart disease: The technique has been widely used in diastology, in hypertrophic cardiomyopathy, in heart transplant patients and in arrhythmology. II--ischemic heart disease: The quantitative assessment of regional diastolic and systolic function makes the technique very promising during stress echocardiography and during percutaneous transluminal coronary angioplasty. CONCLUSIONS: In 2000, tissue Doppler echocardiography is still a young, exciting and promising technique. Despite the fact that much has already been done, there is still a long way to go, implying a great amount of time and personal investment. How often do we feel that we are building a small part of the future?     

Modern evaluation of left ventricular diastolic function using Doppler echocardiography

The evaluation of left ventricular (LV) diastolic function is an essential component of the echocardiographic examination for dyspneic patients with impaired or preserved LV systolic function. Doppler echocardiography in combination with two-dimensional echocardiographic findings can assist the diagnosis of underlying cardiac dysfunction, give an estimate of LV filling pressures, guide heart failure treatment, and provide important prognostic information. This article reviews the essentials of modern Doppler assessment of diastolic function and highlights recent updates, areas of controversy, and future applications.     

组织追踪法测量房室平面位移评价心脏功能研究进展

组织追踪法是基于组织多普勒显像的一种新技术。它通过测定房室平面位移，能够评价心肌的收缩、舒张功能，除了能够评价心脏整体功能，而且更主要应用于评估心室局部功能，因此它在心肌缺血的早期检出、梗死心肌的成活性评价、预测心脏病预后中有重要意义。现综述组织追踪技术测定房室平面位移评价心脏功能的研究进展。     

The right ventricle: role of Doppler echocardiography in clinical practice]

To date, right ventricular function can be clinically assessed by Doppler echocardiography. Monodimensional and two-dimensional echocardiography provide information about right ventricular dimensions, wall thickness and tricuspid annular plane systolic excursion, which is an accurate estimate of longitudinal systolic function. Additional insights into right ventricular systolic function are given by Doppler interrogation of right ventricular outflow, measuring the duration of systolic time intervals. The Doppler recordings of the tricuspid inflow and hepatic venous flow allow the assessment of right ventricular diastolic properties. Also the new ultrasound technologies are clinically useful. The myocardial velocities and time intervals, detectable by pulsed tissue Doppler at the level of the tricuspid annulus, are markers of systolic and diastolic longitudinal motion of the right ventricle. The off-line strain rate imaging permits quantification of right ventricular myocardial contractility and may be particularly useful for the assessment of congenital cardiomyopathies. The right ventricular filling pressure and pulmonary arterial pressure may be derived by the combined analysis of the grade of tricuspid regurgitation and the respiratory reactivity of the inferior vena cava. The systolic time intervals, measured at the level of the right ventricular outflow, represent estimates of changes in pulmonary vascular resistance. The prognostic value of Doppler echocardiographic measurements of right ventricular function is demonstrated in various pathologies. This evaluation also provides additional value for the risk stratification of patients with chronic heart failure.     

Detection of early systolic dysfunction with strain rate imaging in a patient with light chain cardiomyopathy

Congestive heart failure (CHF) in cardiac amyloidosis has been attributed to the development of diastolic dysfunction, because severe CHF symptoms have been observed despite a normal or only mildly reduced LV ejection fraction (EF). An early impairment of longitudinal systolic function has been described by means of tissue Doppler-derived myocardial deformation imaging ('strain rate imaging', SRI).Our patient presented with signs of CHF and significantly increased brain-natriuretic peptide (BNP) levels. Conventional measures of systolic contractile function were within the normal range and mitral inflow Doppler showed only moderate diastolic dysfunction. Histopathological examination by endomyocardial biopsy revealed interstitial deposition of amyloid fibers. Quantitative assessment of myocardial velocities (TDI) and deformation properties (Strain) from the apical view demonstrated a significant impairement of systolic longitudinal myocardial function.In patients with isolated diastolic dysfunction detected by conventional Doppler echocardiography, the quantitative assessment of myocardial strain and strain rate can be helpful in the early detection of systolic dysfunction.     

Noninvasive assessment of systolic and diastolic left ventricular function in patients with chronic severe anemia: a combined M-mode, two-dimensional, and Doppler echocardiographic study.

Thirty-one patients with chronic severe anemia of more than 3 months' duration (hemoglobin less than 7 gm/dl) and no underlying heart disease were studied by means of M-mode, two-dimensional, and Doppler echocardiography; an equal number of normal control subjects was also studied. There are conflicting reports regarding the influence of chronic severe anemia on systolic myocardial function, but diastolic function has not been systematically assessed. It is also uncertain whether anemia alone can cause heart failure in a structurally normal heart. We therefore performed a detailed study of echocardiographic indexes of systolic and diastolic left ventricular function in these patients. We found that patients with anemia have significantly faster heart rates and lower diastolic and mean blood pressures than normal subjects. They also have a significantly elevated cardiac output and stroke volume and larger left ventricles. Left ventricular contractility, assessed by the end-systolic stress-dimension relationship, was enhanced. There was no systematic evidence of diastolic dysfunction by Doppler assessment of mitral inflow. There was also no clinical evidence of congestive heart failure. We conclude that chronic severe anemia leads to a hyperdynamic state with systolic hyperfunction and no impairment of diastolic function. Anemia does not lead to congestive heart failure in the absence of underlying heart disease.     

Evaluation of Regional Myocardial Function by Doppler Tissue Imaging in Univentricular Heart after Successful Fontan Repair

Background: The univentricular heart (UVH) corrected by Fontan repair is characterized by a single dilated pumping chamber, which is both hypertrophic and hypocontractile. The complex geometrical distortion and asynchronous contraction of this organ prevents assessment of systolic and diastolic function by traditional echocardiographic procedures. Methods: Sixteen children (10 males, 6 females) aged 12–31 years, who had undergone UVH Fontan repair were enrolled in the study. A transthoracic echocardiography was performed. Twelve different myocardial wall segments from single ventricles were studied by Doppler tissue imaging to measure peak systolic velocity (S), isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and E′/A′ ratio. Results: S and E′/A′ ratio were significantly lower in the UVH group than in controls (P < 0.01 and P < 0.05, respectively). IRT and ICT were significantly longer in UVH than in controls (P < 0.001 and P < 0.005, respectively). In the UVH, both systolic and diastolic deficits were generally registered in the apical segments and also randomly distributed between the basal and middle segments of the single ventricle. Conclusions: It is an acknowledged fact that compared to normal children ventricular function is impaired in patients with UVH. Tissue Doppler imaging at multiple points of the single ventricle provides a complete, accurate assessment of systolic and diastolic function after Fontan repair, overcoming problems posed by geometrical distortion and limitations of conventional echocardiographic methods. (Echocardiography 2010;27:702‐708)     

Assessment of ventricular diastolic function.

A large number of patients suspected of having congestive heart failure have normal left ventricular systolic function and may, therefore, have primary diastolic heart failure. This diagnosis, however, should not be made unless there is also objective evidence of diastolic dysfunction, ie, signs of abnormal left ventricular relaxation and/or diastolic distensibility. The most useful noninvasive diagnostic approaches are the measurement of transmitral and pulmonary venous flow velocities by pulsed wave Doppler, and mitral annulus velocities by tissue Doppler echocardiography. In some patients, the assessment of intraventricular flow propagation by colour M-mode Doppler echocardiography provides additional information. Diastolic heart failure is most often due to coronary artery disease and/or hypertension; therefore, other noninvasive or invasive tests are needed to define the etiology of myocardial dysfunction. However, in the few patients who have constrictive pericarditis, the Doppler echocardiographic assessment of diastolic filling provides the most important clues to the etiology of the disease. Doppler echocardiographic assessment of left ventricular filling may also be used to obtain semiquantitative estimates of left ventricular diastolic pressure. Furthermore, left ventricular filling patterns, in particular, the deceleration time of early transmitral filling, are powerful predictors of patient prognosis. It is probably not cost effective to perform a comprehensive assessment of diastolic filling in every patient undergoing an echocardiographic examination. However, in selected patients, the assessment of diastolic filling provides information that is important for patient management.