Evaluation of mitral regurgitation by pulmonary venous blood flow patterns. Relation to angiographic and haemodynamic parameters in subgroups of patients

Summary. Objectives: to study the relationship between pulmonary venous systolic flow fraction (PVSFfr) recorded using pulsed Doppler transesophageal echocardiography and angiographic grading and haemodynamic parameters in subgroups of patients with mitral regurgitation. Background: reversed systolic pulmonary venous flow is a sensitive sign of severe mitral regurgitation. Scarse data are available regarding the effects of atrial fibrillation and coronary artery disease. Methods: PVSFfr was calculated as the systolic flow velocity integral divided by the total inflow integral. PVSFfr is negative when systolic flow is dominantly reversed. 111 patients were studied. Results: PVSFfr<0 was 91% sensitive for angiographic severe mitral regurgitation (MR) (specificity 75%). In patients with sinus rhytm and without coronary artery disease the sensivity was 100% and specificity was 86% (n= 25). PVSFfr correlated to angiographic grade (r= -0.63, P= 0.0001), mean PCW (r= -0.63, P= 0.0001), v-wave (r=-0.72, P= 0.0001), systolic blood pressure (r= 0.28, P= 0.003) and left atrial diameter (r= -0.42, P= 0.0001) (n= 111). Stepwise linear regression analysis revealed the v-wave, angiographic grading, left atrial diameter and systolic blood pressure to be independent predictors of PVSFfr. Subgroup analysis revealed a correlation (r= 0.85, n= 25) between angiographic grading and PVSFfr in patients with sinus rhythm without CAD and (r= 0.35, n= 23) in patients with CAD in atrial fibrillation. Conclusions: PVSFfr is valuable in assessing mitral regurgitation. In the presence of atrial fibrillation and coronary artery disease the correlation with angiographic grading decreases indicating the dynamic nature of this valvular lesion.     

Assessment of left ventricular diastolic function from mitral annulus motion,a comparison with pulsed Doppler measurements in patients with heart failure

Summary. Mitral and pulmonary venous flow velocity recordings are often used for the assessment of left ventricular diastolic function. These curves are, however, also influenced by other factors. To investigate whether mitral annulus motion carries additional information in this context, mitral annulus motion was compared to Doppler registrations of mitral and pulmonary flow velocities in 38 patients with heart failure (NYHA II—III) after myocardial infarction. Patients with an increased atrial contribution to mitral annulus motion (> 57%, n= 12) had a higher mitral late-to-early flow velocity ratio (A/E) and pulmonary systolic to diastolic filling ratio (<0–01). Patients with atrial displacement above average for the group (? 5.1 mm, n= 19) had a higher mitral AVE ratio and pulmonary systolic to diastolic filling ratio than patients with a lower than average atrial component (P < 0.05). There was a significant correlation between a/T ratio and A/E ratio (r= 0.61, P < 0.001) and between pulmonary flow and transmitral flow (= 0.76, P < 0.001). We conclude that an increased atrial displacement of the mitral annulus is a frequent finding in patients with signs of left ventricular relaxation abnormality. There is a significant correlation between a/T ratio and A/E ratio but the information contained in the two indices are not identical.     

Transesophageal color flow Doppler mapping in the assessment of native mitral valvular regurgitation: comparison with left ventricular angiography.

Transesophageal echocardiography (TEE) was performed within 24 hours after cardiac catheterization in 45 patients for assessment of native mitral valvular regurgitation. Color flow mapping was used in evaluating systolic regurgitant jet sizes. A jet demonstrated by TEE was 96% sensitive and 44% specific for angiographic mitral regurgitation. The presence of angiographic mitral regurgitation was best predicted by (single measurement) (1) a holosystolic jet, (2) a jet length greater than 2.5 cm, and (3) a jet area greater than 2 cm2. Severe angiographic mitral regurgitation (grades 3 and 4) was best predicted by (single measurement) (1) a jet area greater than 5 cm2, and (2) a jet length greater than 4 cm. It is concluded that the assessment of angiographic mitral regurgitation by TEE is improved by the measurement of these jet parameters, which have a high sensitivity and higher specificity than the presence of a jet alone. Furthermore, with TEE one is able to differentiate severe (grades 3 and 4) from absent or mild mitral regurgitation (grades 0, 1, and 2).     

Correlation of the myocardial performance index with plasma B-type natriuretic peptide levels in patients with mitral regurgitation

Objective The Myocardial performance index (MPI) is an echocardiographic index of combined systolic and diastolic function, calculated as isovolumetric relaxation time plus isovolumetric contraction time divided by ejection time. The aim of this study was to define the correlation of the MPI with plasma B-type natriuretic peptide (BNP) levels and echocardiographic parameters in patients with chronic mitral regurgitation (MR). Methods About 33 patients with at least moderate MR of organic etiology were enrolled to the study. All patients undergone complete 2D and Doppler echocardiography. Plasma BNP levels were studied. Results BNP levels in NYHA classes I–III were 9.3 ± 2.2 pg/ml, 61.3 ± 12.2 pg/ml, and 199.6 ± 55.2 pg/ml, respectively (I vs. II P < 0.001, I vs. III P < 0.001 and II vs. III P = 0.004). Myocardial performance index were 0.42 ± 0.02, 0.49 ± 0.02, and 0.52 ± 0.03 in MR patients with NYHA I–III, respectively. MPI was significantly higher in patients with NYHA class III compared to NYHA I (P = 0.001) and NYHA II (P = 0.005). There were no correlations between MPI and left atrial diameter, MR jet area, MR index and systolic pulmonary artery pressure whereas left ventricle (LV) end-systolic volume (r = 0.38), LV end-diastolic volume (LVDV) (r = 0.40), LV ejection fraction (r = −0.59), NYHA class (r = 0.51) and plasma BNP levels (r = 0.67) were strongly correlated. Only independent variable affecting MPI was plasma BNP level (odds ratio [CI]: 2.18[0.002−0.098], P = 0.041). Conclusions MPI is a powerful index in assessing the severity of left ventricular function and symptom severity in patients with MR. Plasma BNP is an independent predictor of MPI where both parameters assess combined systolic and diastolic LV function, effectively.     

Left atrial appendage functions in patients with severe rheumatic mitral regurgitation

Aim The left atrial appendage (LAA) function was evaluated in patients with severe rheumatic mitral regurgitation, having sinus rhythm or atrial fibrillation, by standard and tissue Doppler echocardiographic examinations. Methods and results Sixty patients with rheumatic severe mitral regurgitation were enrolled. The patients (14 females and 6 males) having sinus rhythm were selected as group I and 20 patients (15 females and 5 males) with atrial fibrillation formed group II. 20 healthy subjects (15 female and 5 males) served as the control group (group III). In order to determine the LAA functions, LAA peak filling flow velocity (LAAPFV), LAA peak emptying flow velocity (LAAPEV) and percentage of LAA area change (LAAAC %) were measured. In the TDI records of the subjects with sinus rhythm, the first positive wave identical to the LAA late emptying wave (LEW) following the P-wave was accepted as LAA late systolic wave (LSW), and the second negative wave identical to the LAA late filling flow was accepted as late diastolic wave (LDW). In patients with atrial fibrillation, the positive wave was accepted as LAA late systolic wave (LSW), and the second negative wave identical to the LAA late filling flow was accepted as late diastolic wave (LDW). LAA outflow and inflow velocities were lower in the group having atrial fibrillation (P < 0.002, and P < 0.007, respectively). LAAAC% was also reduced in group II (P < 0.0001). The pulsed Doppler LSW and LDW velocities, measured with TDI method were found to be quite reduced in patients with AF (P: 0.002 and P: 0.001, respectively). The study parameters were statistically similar in patients with normal sinus rhythm and controls. Conclusion In this study, we found that the LAA functions are impaired in patients with severe mitral regurgitation, having AF, whereas preserved in patients with normal sinus rhythm, compared to controls.     

Pulmonary venous flow determinants of left atrial pressure under different loading conditions in a chronic animal model with mitral regurgitation

Background: The aim of our study was to quantitatively compare the changes and correlations between pulmonary venous flow variables and mean left atrial pressure (mLAP) under different loading conditions in animals with chronic mitral regurgitation (MR) and without MR. Methods: A total of 85 hemodynamic conditions were studied in 22 sheep, 12 without MR as control (NO-MR group) and 10 with MR (MR group). We obtained pulmonary venous flow systolic velocity (Sv) and diastolic velocity (Dv), Sv and Dv time integrals, their ratios (Sv/Dv and Sv/Dv time integral), mLAP, left ventricular end-diastolic pressure, and MR stroke volume. We also measured left atrial a, x, v, and y pressures and calculated the difference between v and y pressures. Results: Average MR stroke volume was 10.6 ± 4.3 mL/beat. There were good correlations between Sv (r = −0.64 and r = −0.59, P < .01), Sv/Dv (r = −0.62 and r = −0.74, P < .01), and mLAP in the MR and NO-MR groups, respectively. Correlations were also observed between Dv time integral (r = 0.61 and r = 0.57, P < .01) and left ventricular end-diastolic pressure in the MR and NO-MR groups. In velocity variables, Sv (r = −0.79, P < .001) was the best predictor of mLAP in both groups. The sensitivity and specificity of Sv = 0 in predicting mLAP 15 mm Hg or greater were 86% and 85%, respectively. Conclusion: Pulmonary venous flow variables correlated well with mLAP under altered loading conditions in the MR and NO-MR groups. They may be applied clinically as substitutes for invasively acquired indexes of mLAP to assess left atrial and left ventricular functional status. (J Am Soc Echocardiogr 2002;15:1181-8.)     

4D flow MRI left atrial kinetic energy in hypertrophic cardiomyopathy is associated with mitral regurgitation and left ventricular outflow tract obstruction

To noninvasively assess left atrial (LA) kinetic energy (KE) in hypertrophic cardiomyopathy (HCM) patients using 4D flow MRI and evaluate coupling associations with mitral regurgitation (MR) and left ventricular outflow tract (LVOT) obstruction. Twenty-nine retrospectively identified patients with HCM underwent 4D flow MRI. MRI-estimated peak LVOT pressure gradient (?P_MRI) was used to classify patients into non-obstructive and obstructive HCM. Time-resolved volumetric LA kinetic energy (KE_LA) was computed throughout systole. Average systolic (KE_LA-avg) and peak systolic (KE_LA-peak) KE_LA were compared between non-obstructive and obstructive HCM groups, and associations to MR severity and LVOT ?P_MRI were tested.The study included 15 patients with non-obstructive HCM (58.6 [45.9, 65.2] years, 7 females) and 14 patients with obstructive HCM (51.9 [47.6, 62.6] years, 6 females). Obstructive HCM patients demonstrated significantly elevated instantaneous KE_LA over all systolic time-points compared to non-obstructive HCM (P?<?0.05). Obstructive HCM patients also demonstrated higher KE_LA-avg (14.8 [10.6, 20.4] J/m³ vs. 33.4 [23.9, 61.3] J/m³, P?<?0.001) and KE_LA-peak (22.1 [15.9, 28.7] J/m³ vs. 57.2 [44.5, 121.4] J/m³, P?<?0.001) than non-obstructive HCM. MR severity was significantly correlated with KE_LA-avg (rho?=?0.81, P?<?0.001) and KE_LA-peak (rho?=?0.79, P?<?0.001). LVOT ?P_MRI was strongly correlated with KE_LA metrics in obstructive HCM (KE_LA-avg: rho?=?0.86, P?<?0.001; KE_LA-peak: rho?=?0.85, P?<?0.001).In HCM patients, left atrial kinetic energy, by 4D flow MRI, is associated with MR severity and the degree of LVOT obstruction.

     

Associations between Doppler ultrasound-derived luteal blood flow indices and functional hormonal profile in spontaneous and stimulated cycles

The associations between Doppler ultrasound-derived luteal blood flow indices and luteal hormonal profile in the midluteal phase were assessed in both spontaneous and stimulated cycles. Transvaginal color Doppler ultrasound evaluation and blood sampling were carried out prospectively on 61 infertility patients in 43 spontaneous cycles, 31 clomiphene citrate (CC) cycles, and 16 controlled ovarian hyperstimulation (COH) cycles in the midluteal phase. Luteal blood flow Doppler indices included peak systolic veloicty (PSV), time-averaged maximum velocity (TAMXV), pulsatile index (PI), and resistance index (RI). Hormonal profile indices included serum levels of 17 β-estradiol (E₂), progesterone (P) and P/E₂ ratio. The correlation between each end-point in each treatment group was assessed by regression analysis. PSV and TAMXV in the COH group were significantly higher than in the spontaneous group (P=0.0435 vsP=0.0359, respectively). Serum E₂ and P were significantly higher than in the spontaneous group (P=0.0435 vsP=0.0359, respectively). Serum E₂ and P levels were significantly higher in the COH group than in the CC (P<0.0001 vsP<0.0001, respectively) and spontaneous groups (P<0.0001 vsP<0.0001, respectively). PSV and TAMXV correlated positively with P level in spontaneous cycles (P=0.0131 vsP=0.0142, respectively) and CC (P=0.0120 vsP=0.0066, respectively) but correlated negatively P level in COH cycles (P=0.0348 vsP=0.0383, respectively). PI and RI correlated with P only in CC cycles (P=0.0357 vsP=0.0369, respectively). Doppler ultrasound-derived indices all correlated with P/E₂ ratio in spontaneous and CC cycles but not in COH cycles. These results indicate that velocity indices should be considered as complementary parameters of luteal function for infertility but that the relationship of these indices to P level in COH cycles differs from that in spontaneous and CC cycles. The correlation of luteal blood flow indices with P/E₂ ratio suggests that Doppler ultrasound indices may be useful in predicting reproductive outcome in spontaneous and CC cycles.     

New quantitative three-dimensional echocardiographic indices of mitral valve stenosis

Background We studied the value of quantitative three-dimensional echocardiography (3DE) in the evaluation of mitral valve stenosis using the measurement of the mitral valve area (MVA) with two new indices: the doming volume and mitral valve volume. Methods and results A total of 45 consecutive patients with mitral valve stenosis were studied. MVA was measured using Doppler with the pressure half-time (PHT) method. Following a diagnostic multiplane transesophageal (TEE) examination, data for 3DE were acquired with a rotational mode of acquisition. MVA was assessed by anyplane echocardiography (APE) and from surface rendered images. Moreover, the doming volume, i.e., the volume subtended by the anterior and posterior mitral valve and annular cut plane was measured by APE. Comparing PHT-derived with 3DE-derived MVA’s, using both APE and surface rendered images, only moderate correlations were observed: PHT-derived MVA versus APE-derived MVA: r = 0.74, P < 0.0001; PHT-derived area versus 3DE-surface rendered MVA: r = 0.70, P < 0.0001. Multiple linear regression analysis showed a relation of atrial fibrillation to the doming volume (P = 0.04), but not to PHT-derived MVA (P = 0.28), APE-derived area (P = 0.33) and mitral valve volume (P = 0.08). Comparison of patients with MVA < 1 cm² and MVA > 1 cm² revealed significant difference in mitral valve volume: mean mitral valve volume in critical stenosis was 3.7 ml versus 1.4 ml in non-critical stenosis (P = 0.04). Conclusions Only moderate correlations between 3DE and Doppler-derived MVA’s were observed. Measurement of the doming volume allows quantification of the 3DE geometry of the mitral apparatus. Patients with conical or funnel-like geometry are more likely to have sinus rhythm, whereas, patients with flat geometry are likely to have atrial fibrillation. Mitral valve volume can be used for the evaluation of mitral stenosis severity. These new 3DE indices might be used for selection of patients for balloon valvuloplasty.     

Mitral annular velocity by Doppler tissue imaging for the evaluation of atrial stunning after cardioversion of atrial fibrillation

Objective Atrial and/or appendage stunning (AS) usually occur after successful cardioversion of atrial fibrillation (AF). Several parameters except mitral annular velocity were previously evaluated to determine AS. We investigated whether mitral annular velocity was useful for determining of AS. Methods This study consisted of 52 consecutive patients with AF <3 months who converted to the sinus rhythm. Mitral inflow and annular velocities were measured before and after cardioversion. Left atrial appendage (LAA) size and flow were assessed. The average velocity of septal and lateral segments of mitral annulus was considered as the final annular velocity. Thrombus and/or spontaneous echo contrast (SEC) were also investigated. Results Of 52 patients, 29 (56%) had AS but 23 did not. There was no significant difference in age, gender, and cardioversion type between two groups. Hypertension was more prevalent in patients without AS compared to those with AS (P = 0.02). Mitral annular systolic and E-wave velocities were comparable in both groups (P > 0.05). Mitral annular A-wave velocity (3.1 ± 2.9 vs. 7.1 ± 2.2 cm/s, P < 0.001), and its velocity-time integral (0.27 ± 0.22 vs. 0.74 ± 0.19 cm, P < 0.001) were significantly lower in patients with AS compared with those without AS. The annular A-wave velocity ≤3.3 cm/s predicted AS with a sensitivity of 59% and specificity of 76%. It was correlated with mitral inflow A velocity (r = 0.85, P < 0.001), LAA emptying velocity (r = 0.41, P = 0.003) and presence of SEC (r = −0.52, P < 0.001). Conclusion After cardioversion of AF, mitral annular A-wave velocity may be a new marker to determine AS.     

心肌做功技术评估急性心肌梗死患者左心室收缩功能

目的 探讨心肌做功（MW）技术评估急性心肌梗死（AMI）患者左心室收缩功能的应用价值。方法 对比30例AMI患者（AMI组）与30名健康志愿者（对照组）的常规超声心动图参数及MW参数，分析AMI患者左心室整体有用功（GCW）与左心室射血分数（LVEF）、整体长轴应变（GLS）之间的相关性。结果 与对照组比较，AMI组左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、室间隔舒张末期厚度（IVSD）、左心室舒张末期容积（LVEDV）、左心室收缩末期容积（LVESV）、二尖瓣口舒张早期峰值流速（E）/二尖瓣后叶瓣环组织多普勒速度（e）、左心室质量（LVM）、左心室质量指数（LVMI）及二尖瓣反流面积（MR）均增大，LVEF、E及e值均减低（P均<0.05）；左心室GCW、整体做功效率（GWE）、整体做功指数（GWI）均降低，整体无用功（GWW）、GLS、峰值应变离散度（PSD）均增高（P均<0.05）。AMI患者GCW与LVEF呈正相关（r=0.573，P=0.001），GCW与GLS呈负相关（r=-0.880，P<0.001）。结论 MW技术可用于评估AMI患者左心室收缩功能变化。     

Increased serum oxidative stress in patients with severe mitral regurgitation: A new finding and potential mechanism for atrial enlargement

ObjectiveThe aim of this study was to examine the serum oxidative stress in patients with severe mitral regurgitation.Design and methodsThis study analyzed serum oxidative stress index in patients with severe mitral regurgitation [persistent atrial fibrillation (AF) or sinus rhythm], paroxysmal lone AF patients and healthy subjects.ResultsThe serum oxidative stress index was significantly higher in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p < 0.0001). Left atrial size was significantly larger in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p < 0.0001). The oxidative stress index significantly and positively correlated with left atrial size in the overall study population (r = 0.439, p = 0.0008).ConclusionsThis study provides new evidence of increased oxidative stress in human severe mitral regurgitation, probably contributing to atrial enlargement.     

<Superscript>123</Superscript>I-BMIPP and <Superscript>99m</Superscript>Tc-TF discordance on myocardial scintigraphy and it’s correlation with functional recovery following acute myocardial infarction: role of conventional echocardiography

¹²³I-β-methyl-iodophenyl pentadecanoic acid (BMIPP) and ^99mTc-Tetrofosmin (TF) mismatch designated as stunned myocardium having both systolic and diastolic components. The degree of mismatch might reflect subsequent functional improvement, and this study was designed to unravel the impact of mismatched defect score (MMDS) on recovery of both systolic and diastolic function following acute myocardial infarction (AMI). Forty patients with recent AMI were recruited, and all of them underwent emergency percutaneous coronary intervention. Echocardiography and BMIPP and TF cardiac scintigraphy were performed on 7 ± 3 days of admission. Follow up echocardiography was performed after 3 months. MMDS were compared with the systolic [ejection fraction (EF) and wall motion score index (WMSI)] and diastolic [peak velocity of early diastolic filling of mitral inflow/peak early diastolic velocity of the mitral annulus(E/E′) and left atrial volume index(LAVI)] parameters. BMIPP defect score was significantly higher than the TF defect score and there was a strong positive correlation between them (r = 0.90, P < 0.00001). Thirty-two (80%) patients showed mismatched defect and rest 8(20%) showed matched defect. Of 32 patients 24(75%), 22(69%), 19(59%), and 20(62.5%) showed improved EF, WMSI, E/E′ and LAVI respectively. Conversely out of 8 only 2(25%), 1(12.5%), and 2(25%) patients showed improvement of EF, WMSI and LAVI, respectively. E/E′ was not improved in patients with matched defect. MMDS were significantly correlated with the improvement of EF (r = −0.46, P = 0.002), WMSI (r = 0.41, P = 0.007), E/E′ (r = 0.56, P < 0.0002), and LAVI (r = 0.44, P = 0.004). Mismatched defect score could predict the approximate amount of viable dysfunctional myocardium, and the degree of mismatch showed a significant correlation with the improvement of both systolic and diastolic function.     

Relationship between mitral leaflets angles, left ventricular geometry and mitral deformation indices in patients with ischemic mitral regurgitation: imaging by echocardiography and cardiac magnetic resonance

Chronic ischemic mitral regurgitation (IMR) is associated with a markedly worse prognosis after myocardial infarction (MI).The study aimed to evaluate the relationship between anterior and posterior mitral leaflet angle (MLA) values, left ventricle remodeling and severity of ischaemic mitral regurgitation (IMR). Methods: Forty-two patients (age 63.5 ± 9.7 years, 36 men) with chronic IMR (regurgitant volume, RV > 20 ml; >6 months after MI) underwent transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR) imaging. Anterior and posterior MLA, determined by echocardiography, were correlated with indices of LV remodeling, mitral apparatus deformation and IMR severity by CMR. The anterior and posterior MLA was 25.41 ± 4.28 and 38.37 ± 8.89° (mean ± SD). In 5 patients (11.9%) the posterior MLA was ≥45°. There was a significant correlation between anterior MLA and RV (r = 0.74, P = 0.01). For patients with RV > 30 ml this correlation was stronger (r = 0.97, P = 0.005) and, in addition, there was a correlation between the RV and posterior MLA (r = 0.90, P = 0.037), between tenting area and posterior MLA (r = 0.90, P = 0.04), and between tenting area and anterior MLA (r = 0.82, P = 0.08). With regard to LV remodeling parameters, there was weaker but significant correlation between posterior MLA and LV end-diastolic volume index (r = 0.35, P = 0.031), LV end-systolic volume index (r = 0.37, P = 0.021), stroke volume (r = 0.35, P = 0.03), sphericity index (r = 0.33, P = 0.041). Anterior MLA correlated with wall motion score index (r = 0.41, P = 0.019). Besides, there was a correlation between posterior MLA and left atrial volume (r = 0.41, P = 0.012). Measurement of anterior and posterior MLA may play an important role in evaluating patients with IMR.     

Is E/E′ reliable in patients with regional wall motion abnormalities to estimate left ventricular filling pressure?

Background There is limited data on the diagnostic utility of the transmitral to mitral annular velocity (E/E′) by tissue Doppler imaging (TDI) in the presence of regional wall motion abnormalities (RWMA). We aimed to investigate whether the E/E′ is reliable in estimating left ventricular filling pressure (LVFP) despite RWMA. Methods One hundred thirty consecutive patients with myocardial infarction (MI) and subsequent RWMA referred for cardiac catheterization and echocardiography to measure LV pre-A pressure (LVP_PRE-A) and Doppler signals from the mitral inflow with tissue Doppler imaging (TDI) of the mitral annulus. All patients were classified into three groups according to RWMA of the segment adjacent to the E′-measuring point using TDI: 83 patients with normal wall motions of the basal septal and basal lateral segments (group A); 28 patients with RWMA of the basal septum (group B); and 19 patients with RWMA of the basal lateral segment (group C). Results Septal E/E′ correlated with LVP_PRE-A in groups A and C (r = 0.383, P < 0.001; r = 0.482, P = 0.037, respectively). Lateral E/E′ and LVP_PRE-A showed good correlation in groups A, B and C (r = 0.470, P < 0.001; r = 0.416, P = 0.028; r = 0.727, P < 0.001, respectively). The largest area under the receiver operating curve was obtained by the lateral E/E′ for the prediction of a high LVFP, irrespective of the location of RWMA. Conclusions In selected patients with abnormal wall motion of the basal septum, E/E′ measured at the septum was not representative for LVFP. Lateral E/E′ is reliable for the prediction of high LVFP, regardless of the site of RWMA.     

Correlation between clinical features and circulating levels of soluble intercellular adhesion molecule-1 in Hodgkin's disease

Summary Previous reports have suggested soluble intercellular adhesion molecule-1 as a marker of disease activity in Hodgkin's disease. In the present study we investigated serum levels of intercellular adhesion molecule-1 at diagnosis in 104 patients with Hodgkin's disease and in 77 of these patients following the achievement of complete remission (within 12 months of diagnosis). Mean serum levels at diagnosis were significantly higher in patients than in controls (P<0.0001) and were related to advanced stages of disease (P=<0.0001) presence of “B” symptoms (P<0.0001), abnormality of laboratory indexes (P<0.0001), erythrocyte, sedimentation rate values (r=0.41,P<0.0001) and serum levels of soluble interleukin-2 receptor α chain (r=0.51,P<0.0001). Mean values in complete remission were significantly lower than at diagnosis (P=0.003). Lower mean values at diagnosis were detected in 30 patients with advanced disease who attained complete remission, compared with 6 patients who failed to attain complete remission with standard treatment. We conclude that in Hodgkin's disease, high serum levels of soluble intercellular adhesion molecule-1 are detectable at presentation and strictly correlate with some clinical features. Response to treatment is paralleled by reduced serum levels. Larger prospective studies are needed to evaluate the possible prognostic significance of serum levels of soluble intercellular adhesion molecule-1 at diagnosis.     

Clinical application in routine practice of the proximal flow convergence method to calculate the mitral surface area in mitral valve stenosis

Background: Two-dimensional (2D) echocardiography planimetry, the Doppler pression half-time (PHT), and the continuity equation methods were used to estimate mitral valve area (MVA) in patients with mitral stenosis (MS). Recently, the proximal isovelocity surface area (PISA) method has been shown to be accurate for calculating MVA. The purpose of this study is (1) to compare in a large non-selected population the accuracy of the PISA and planimetry methods for echocardiographic estimation of MVA; (2) to determine the effect of atrial fibrillation (AF), Wilkins score, associated mitral regurgitation (MR), aortic regurgitation (AR), and of commissural calcifications on the accuracy of the PISA method. Methods: One hundred and eight consecutive patients with rheumatic MS were studied (76 females and 32 males; mean age: 36 ± 12 years); 64 were in sinus rhythm; 51 had associated MR and 46 had AR. By the PISA method, MVA was calculated assuming a uniform radius flow convergence region along a hemispherical surface. Results: The mean value of 2D MVA was 1.32 ± 0.59 cm² (0.4–3.1 cm²) and that of PISA MVA 1.33 ± 0.62 cm² (0.38–3 cm²). MVA calculated using the PISA method correlated well with 2D MVA (r = 0.93, y = 0.97x + 0.04, p < 0.0001, SEE = 0.21 cm²). The correlation was also good in patients with AF (r = 0.93, y = 0.99x + 0.03, p < 0.0001, SEE = 0.21 cm²), with MR (r = 0.94, y = 1.014x + 0.003, p < 0.0001, SEE = 0.19 cm²), with AR (r = 0.93, y = 0.90x + 0.11, p < 0.0001, SEE = 0.2 cm²), when Wilkins score was >8 (r = 0.92, y = 0.96x + 0.06, p < 0.0001, SEE = 0.19 cm²), and in patients with commissural calcifications (r = 0.90, y = 0.88x + 0.009, p < 0.0001, SEE = 0.20 cm²). Conclusion:Our study shows that in routine practice, MVA calculated by the PISA method correlated well with the area obtained by planimetry even in the presence of commissural calcifications, associated MR, AR, AF and of high Wilkins score. Therefore, the PISA method provides a reliable measurement of the MVA in MS under different anatomic and clinical conditions and may be a useful alternative method for calculating MVA.     

The relationship between tissue Doppler imaging and seric NTproBNP levels in sinus rhythm patients: a prospective study

N-terminal pro-brain natriuretic peptide (NTproBNP) correlates with left ventricular (LV) filling pressure. The ratio between early diastolic transmitral velocity and early mitral annular diastolic velocity (E/Ea) reflects LV filling pressure in a variety of cardiac diseases. However this relationship was not validated in some categories of patients. Our aim was to evaluate the correlation between tissue Doppler velocities of the mitral annulus and NTproBNP levels in sinus rhythm patients. Methods Echocardiography was performed in 111 consecutive patients simultaneously with NTproBNP measurement. E/Ea and E/(Ea × Sa) were calculated (Sa is the maximal systolic velocity of mitral annulus); the average of the velocities of septal and lateral mitral annulus was used. Results Simple regression analysis demonstrated a significant linear correlation between E/(Ea × Sa) and NTproBNP (r = 0.71, P < 0.0001), superior to E/Ea correlation (r = 0.58, P < 0.0001). Significant but weaker correlations were found between NTproBNP and Sa, pulmonary artery systolic pressure, Ea, mitral E/A (early/late diastolic transmitral velocity), E wave, mitral E deceleration time and LV ejection fraction (LVEF). The optimal E/(Ea × Sa) cut-off for prediction of NTproBNP levels > 900 pg/ml was 1.5 (sensitivity = 81%, specificity = 70%). Among analyzed parameters, E/(Ea × Sa) was best correlated with NTproBNP levels in patients with LVEF ≥ 50% (r = 0.80, P < 0.0001), with depressed LVEF (<50%) (r = 0.66, P < 0.0001), with regional wall motion abnormalities (r = 0.75, P < 0.0001), and with E/Ea 8 to 15 (r = 0.58, P < 0.0001). Conclusions E/(Ea × Sa) strongly correlates with NTproBNP, regardless of LVEF, and can be a simple and accurate echocardiographic index in patients in sinus rhythm, particularly in those with regional wall motion abnormalities or intermediate E/Ea.     

实时三维TEE评价犬二尖瓣对合程度与二尖瓣反流程度的关系

目的建立急性二尖瓣反流动物模型,应用实时三维TEE(RT-3D-TEE)分析犬心脏出现二尖瓣中度及中度以上反流时所对应的二尖瓣对合指数的截断值。方法应用15只健康犬建立二尖瓣中度及中度以上反流模型,以Phil-ips iE33超声心动成像仪分别于基础状态下、过度压力状态下及出现二尖瓣中度及中度以上反流状态时获取原始数据,对超声数据进行分析得出二尖瓣对合指数,利用ROC曲线确定截断值。对实验犬二尖瓣前后叶粗糙带进行染色,以获得实体二尖瓣对合指数。结果基础状态下超声所测二尖瓣对合指数与二尖瓣对合指数实体测值具有良好的相关性(r=0.76,P<0.05),二尖瓣对合指数与左心室压力呈负相关(r=-0.86,P<0.01);二尖瓣中度及中度以上反流时,二尖瓣对合指数小于基础状态(P=0.045)。二尖瓣出现中度及中度以上反流时,二尖瓣对合指数所对应的ROC曲线下面积为0.89cm2,当二尖瓣对合指数的截断值为19.89%时,敏感度为81.25%、特异度为92.00%。结论RT-3D-TEE测量二尖瓣对合指数可以较好地反映犬二尖瓣的实际对合情况。     

An angiographic technique for coronary fractional flow reserve measurement: in vivo validation

Fractional flow reserve (FFR) is an important prognostic determinant in a clinical setting. However, its measurement currently requires the use of invasive pressure wire, while an angiographic technique based on first-pass distribution analysis and scaling laws can be used to measure FFR using only image data. Eight anesthetized swine were instrumented with flow probe on the proximal segment of the left anterior descending (LAD) coronary arteries. Volumetric blood flow from the flow probe (Q_p), coronary pressure (P_a) and right atrium pressure (P_v) were continuously recorded. Flow probe-based FFR (FFR_q) was measured from the ratio of flow with and without stenosis. To determine the angiography-based FFR (FFR_a), the ratio of blood flow in the presence of a stenosis (Q_S) to theoretically normal blood flow (Q_N) was calculated. A region of interest in the LAD arterial bed was drawn to generate time-density curves using angiographic images. Q_S was measured using a time-density curve and the assumption that blood was momentarily replaced with contrast agent during the injection. Q_N was estimated from the total coronary arterial volume using scaling laws. Pressure-wire measurements of FFR (FFR_p), which was calculated from the ratio of distal coronary pressure (P_d) divided by proximal pressure (P_a), were continuously obtained during the study. A total of 54 measurements of FFR_a, FFR_p, and FFR_q were taken. FFR_a showed a good correlation with FFR_q (FFR_a = 0.97 FFR_q +0.06, r² = 0.80, p < 0.001), although FFR_p overestimated the FFR_q (FFR_p = 0.657 FFR_q + 0.313, r² = 0.710, p < 0.0001). Additionally, the Bland–Altman analysis showed a close agreement between FFR_a and FFR_q. This angiographic technique to measure FFR can potentially be used to evaluate both anatomical and physiological assessments of a coronary stenosis during routine diagnostic cardiac catheterization that requires no pressure wires.