Clinical usefulness of tissue Doppler imaging in predicting preclinical Fabry cardiomyopathy

Fabry cardiomyopathy (FC) is characterized by left ventricular hypertrophy (LVH). The aim of this study is to determine whether early changes revealed by tissue Doppler imaging (TDI) are useful for detecting preclinical cardiac abnormalities in patients with this X-linked genetic disorder. If so, this tool could help in deciding whether to begin enzymatic therapy earlier than otherwise. METHODS AND RESULTS: 59 consecutive patients with confirmed Fabry disease (FD) underwent conventional and TD echocardiography. FD patients with and without LVH had significantly lower early diastolic tissue Doppler velocities (Ea) compared with the control group (P<0.001); The isovolumic relaxation time (IVRT) was significantly longer in the FD group with LVH (P<0.001). Isovolumic contraction time (IVCT) was significantly shorter in the FD group without LVH compared with the control group (P<0.001). Additionally, peak systolic wall motion velocity (Sa) was significantly lower in patients with LVH, compared with those without LVH (P<0.001). The systolic myocardial velocity correlates inversely with septum and posterior wall thickness (r: -0.74 and r: -0.90; P<0.001 respectively). In respect of predicting preclinical cardiac impairment, the area under the ROC curve of 0.83 suggests an optimal IVRT cut-off point of 60 ms for separating early cardiac impairment from the established condition. This gives a 96.6% specificity rate for the early detection of cardiac involvement. The best parameter for detecting preclinical FC is the IVCT, with a cut-off point of 105 ms, which shows high sensitivity and specificity (100% and 91%, respectively; AUC: 0.97). CONCLUSIONS: Myocardial contraction and relaxation evaluation confirms that TDI is a reliable method for early identification of preclinical FC, even before FC patients develop LVH.     

Detection of left ventricular ischemia at rest by tissue Doppler echocardiography

A 53-year old woman without a previous history of cardiac disease was successfully resuscitated from ventricular fibrillation. Despite a normal two dimensional echocardiogram, tissue Doppler analysis of left ventricular long-axis contraction revealed marked postsystolic contractions in the territory of the left coronary artery suggesting ischemia as the underlying pathogenetic mechanism. This was confirmed by coronary angiography which revealed a high-grade ostial stenosis of the left main stem. After coronary artery bypass surgery, the tissue Doppler findings normalized. CONCLUSION: Assessment of regional long axis function by tissue Doppler echocardiography may yield important additional findings even if two-dimensional echocardiography is apparently normal.     

Comparison of left atrial volume parameters in detecting left ventricular diastolic dysfunction versus tissue Doppler recordings

Because of diastolic coupling between the left atrium and left ventricle, we hypothesized that left atrial (LA) function mirrors the diastolic function of left ventricle. The aims of this study were to assess whether LA volume parameters can be good indexes of left ventricular diastolic dysfunction. Six hundred fifty-nine patients underwent cardiac catheterization and measurements of left ventricular filling pressure (LVFP). Echocardiographic examinations including tissue Doppler and LA volumes were also assessed. Ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity and LVFP tended to increase after progression of diastolic dysfunction. The inverse phenomenon existed in LA ejection and LA distensibility. LA distensibility was superior to LA ejection fraction and early diastolic mitral inflow velocity/early diastolic mitral annular velocity for identifying LVFP >15 mm Hg (areas under receiver operating characteristic curve 0.868, 0.834, and 0.759, respectively) and for differentiating pseudonormal from normal diastolic filling (areas under receiver operating characteristic curve 0.962, 0.907, and 0.741, respectively). Multivariate logistic regression showed that LA ejection fraction and LA distensibility were associated significantly with the presence of pseudonormal/restrictive ventricular filling. In conclusion, LA volume parameters can identify LVFP >15 mm Hg and differentiate among patterns of ventricular diastolic dysfunction. For assessing diastolic function LA parameters offer better performance than even tissue Doppler.     

Doppler tissue imaging for assessing left ventricular diastolic dysfunction in heart transplant rejection

OBJECTIVE—To test the hypothesis that diastolic mitral annular motion velocity, as determined by Doppler tissue imaging and left ventricular diastolic flow propagation velocity, is related to the histological degree of heart transplant rejection according to the International Society of Heart and Lung Transplantation (ISHLT).
METHODS—In 41 heart transplant recipients undergoing 151 myocardial biopsies, the following Doppler echocardiographic measurements were performed within one hour of biopsy: transmitral and pulmonary vein flow indices; mitral annular motion velocity indices; left ventricular diastolic flow propagation velocity.
RESULTS—Late diastolic mitral annular motion velocity (A_DTI) and mitral annular systolic contraction velocity (SC_DTI) were higher in patients with ISHLT < IIIA than in those with ISHLT  IIIA (A_DTI, 8.8 cm/s v 7.7 cm/s (p = 0.03); SC_DTI, 19.3 cm/s v 9.3 cm/s (p < 0.05)). Sensitivity and specificity of A_DTI < 8.7 cm/s (the best cut off value) in predicting significant heart transplant rejection were 82% and 53%, respectively. Early diastolic mitral annular motion velocity (E_DTI) and flow propagation velocity were not related to the histological degree of heart transplant rejection.
CONCLUSIONS—Doppler tissue imaging of the mitral annulus is useful in diagnosing heart transplant rejection because a high late diastolic mitral annular motion velocity can reliably exclude severe rejection. However, a reduced late diastolic mitral annular motion velocity cannot predict severe rejection reliably because it is not specific enough.


Keywords: heart transplant rejection; diastolic function; Doppler tissue imaging; echocardiography     

Age- and sex-related differences in the tissue Doppler imaging parameters of left ventricular diastolic dysfunction

BACKGROUND: The effect of age and gender on tissue Doppler imaging measurements comparing the septal and mitral annulus needs to be investigated. METHODS: We investigated in 276 outpatients in a university cardiology practice the relationship of age and gender to left atrial (LA) size, LA volume, mitral pulse-wave Doppler E/A ratio, E/Ea ratios by tissue Doppler image of mitral annular velocity (TDI), and left ventricular diastolic dysfunction (LVDD) by TDI. RESULTS: Mitral E/A inflow was statistically decreased with age. E/Ea ratios of the lateral and mean of both lateral and septal annulus showed a statistical increase with age, while the E/Ea ratio of the septal annulus did not correlate with age. When comparing men and women of all ages, the mean LA volume for men was 59.2 cm3 +/- 24.36 cm3 versus 48.54 cm3 +/- 16.14 cm3 (P-value < 0.0001) and the mean LA size was 4.0 + 0.51 cm for men and 3.65 + 0.47 for women (P-value < 0.0001). There was no statistical difference between men and women when looking at mitral E/A inflow ratio, deceleration time, E/Ea ratio of the septal annulus, E/Ea ratio of the lateral annulus, E/Ea ratio of the mean of both septal and lateral annulus, and grades of LVDD. CONCLUSION: In patients 70 years of age or older, the mean diastolic grade was mild-to-moderate LVDD when using lateral or mean of septal and lateral annular measurements. When only the septal annular measurements were used to determine diastolic grade, all four age groups showed a mean of mildly to moderately impaired LVDD and showed no correlation with age. There were no differences in tissue Doppler imaging measurements between men and women.     

Doppler tissue imaging of the mitral annulus in patients with left ventricular systolic dysfunction. Assessment of diastolic function

INTRODUCTION AND OBJECTIVES: We assessed the Doppler tissue imaging technique in the left mitral annulus of patients with left ventricular systolic dysfunction since the technique has been used to evaluate diastolic function of the left ventricle and the values obtained have been considered to be relatively independent of the preload. PATIENTS AND METHODS: Patients (n = 46) with an ejection fraction < 40% in sinus rhythm without mitral regurgitation underwent pulsed wave Doppler analyses of mitral inflow (E and A waves), pulmonary venous flow (S, D and Ar waves) and Doppler tissue imaging of the mitral annulus (Ea and Aa waves). RESULTS: Overall, the linear correlations between the different Doppler measurements were poor. When sub-grouped with respect to E/A < 1 and E/A >= 1 (Groups 1 and 2, respectively), the Ea value did not significantly differ between the two groups: 5.0 cm/s (4.2/6.0) vs 6.2 cm/s (5.5/8. 2) respectively; p = 0.129 and neither did the E/Ea quotient: 10.2 (8.2/14.5) vs 12.9 (9.1/17.4) respectively; p = 0.160. Atrial size was significantly greater in Group 2: 20.0 cm2 (18.0/22.0) vs 25.0 cm2 (20.0/29.0) respectively; p = 0.000. The Ea/Aa quotient was pseudo-normalized in Group 2: 0.65 (0.48/0.83) vs 1.15 (0.75/1.71) respectively; p = 0.001. CONCLUSIONS: In patients with left ventricular systolic dysfunction the Ea/Aa value tends towards pseudo-normalization when the preload is increased. This does not apply to the values of Ea, E/Ea or to size of the left atrium. Therefore, Doppler tissue imaging of the left mitral annulus is valuable in the assessment of left ventricular dysfunction and the problem of pseudo-normalization due to preloading.     

Screening for Fabry disease in patients with left ventricular noncompaction

Introduction and AimIt is unclear whether left ventricular noncompaction (LVNC) is a distinct cardiomyopathy or a morphologic manifestation of different cardiomyopathies. We previously reported a case of LVNC in a Fabry disease (FD) patient, but it remains to be clarified whether LVNC is a cardiac manifestation of FD, a coincidental finding or an overdiagnosis, which has major therapeutic implications. This study aims to determine the prevalence of FD among patients with LVNC.MethodsWe performed a retrospective study including all patients diagnosed with LVNC in eight hospital centers. Diagnosis of LVNC was based on at least one echocardiographic or cardiac magnetic resonance criterion. FD screening was performed by combined enzyme and genetic testing.ResultsThe study included 78 patients diagnosed with LVNC based on the Jenni (84.6%), Stöllberger (46.2%), Chin (21.8%), Petersen (83.8%) and Jacquier (16.2%) criteria. Left ventricular systolic dysfunction was present in 48.7%. Heart failure was found in 60.3%, ventricular dysrhythmias in 21.6% and embolic events in 11.5%. FD screening found no additional cases among patients with LVNC, besides the previously described case.ConclusionNo additional FD cases were found among patients with LVNC, which argues against the hypothesis that LVNC is a cardiac manifestation of FD.     

The utility of pulsed tissue Doppler parameters for the diagnosis of advanced left ventricular diastolic dysfunction

OBJECTIVE: The evaluation of diagnostic value of pulsed tissue Doppler (TD) parameters (calculated from six points of mitral annulus and separately measured in the lateral part of mitral annulus) for the detection of pseudonormal mitral inflow pattern. METHODS AND RESULTS: Among 200 persons examined by transthoracic echocardiography group with E/A value between 1 and 2 was selected and divided to normal (54 subjects, early wave deceleration time, Edt > or = 150 msec) and pseudonormal (23 patients, Edt < 150 msec together with prolonged difference between duration of atrial reversal flow in pulmonary vein and mitral flow in atrial phase, delta Ar > or = 20 msec) inflow. Wide spectrum of TD parameters was compared between the selected groups. In normal inflow, average peak velocities of early and atrial phase of diastolic mitral annulus motion were significantly higher: 11.0 +/- 2.6 versus 8.9 +/- 3.5 cm/sec; (P = 0.005) and 12.0 +/- 2.2 versus 10.0 +/- 3.0 cm/sec; (P = 0.002), respectively. Ratio of peak early mitral wave velocity to peak velocity of annulus motion in early phase (Ev/E'v avr) was higher in the pseudonormal pattern: 9.8 +/- 3.7 versus 7.0 +/- 2.0, respectively (P < 0.001). For the value of Ev/E'v avr > 10.2, 70% accuracy for the diagnosis of pseudonormalization was detected. For the parameters measured in the lateral part of mitral annulus similar relationships in the early filling phase were detected but did not reach statistical significance in the atrial phase. CONCLUSIONS: Pulsed TD offers good accuracy for the diagnosis of pseudonormalization with increased ratio of peak early mitral wave velocity to peak velocity of mitral annulus being the optimal predictor of advanced diastolic dysfunction.     

Detection of subclinical LV dysfunction by tissue Doppler imaging.

Echocardiography is a well-established clinical tool for theassessment of myocardial function. However, in subclinical diseases,the routinely used echocardiographic parameters such as leftventricular (LV) ejection fraction (EF) and fractional shorteningare not sensitive enough to detect myocardial dysfunction. Wehave learned over the past years that other echocardiographictechniques such as tissue Doppler imaging might be able to describechanges in myocardial performance that go beyond the limitations     

脉冲组织多普勒成像技术检测糖尿病患者左室舒张功能

目的应用脉冲组织多普勒成像技术(PWDTI)检测糖尿病(DM)组和健康对照组左室舒张功能,并与传统二尖瓣血流频谱E/A比较。方法用PWDTI在心尖左室长轴水平二尖瓣环后壁处测量舒张期E峰速度(Ve)、A峰速度(Va),计算Ve/Va比值;在同一切面用彩色多普勒血流显像技术(CDFI)测量二尖瓣口舒张期血流频谱E峰、A峰值,计算E/A比值,并计算E/Ve比值。DM组根据尿蛋白阴性或阳性分为两亚组,并根据糖化血红蛋白(HbA1c)浓度≤或>7%分为两亚组。结果DM组和健康对照组Ve/Va比值[(0.87±0.37)、(1.21±0.4)]以及E/Ve比值[(9.24±4.47)、(6.03±1.72)]差异有统计学意义(P<0.05)。DM组尿蛋白阴性、阳性亚组的E/Ve比值分别为(7.36±2.46)、(10.5±2.49),DM组HbA1c≤7%和>7%亚组E/A比值分别为(0.64±0.24)、(1.32±0.22),两亚组比较均差异有统计学意义(P<0.05)。结论PWDTI观测DM左室舒张功能较传统二尖瓣口血流频谱E/A具有明显的优越性,两者结合起来能更好地反映左室舒张功能。     

Aortic regurgitation. Detection of left ventricular dysfunction by exercise echocardiography.

Left ventricular performance was assessed in 20 symptom free patients and 10 with symptoms, all with isolated aortic regurgitation, by measuring the echocardiographic peak velocity of circumferential fibre shortening (echo peak Vcf) at rest and during graded bicycle ergometer exercise in the supine position. The normal left ventricular response during such exercise was first determined in 20 healthy controls. On the basis of their resting and exercise echo peak Vcf, the 30 patients with aortic regurgitation could be separated into three groups: Group 1 comprised 11 symptom free patients with a normal resting echo peak Vcf which increased normally with exercise; group 2 comprised nine symptom free patients with a normal resting echo peak Vcf but with a subnormal response to exercise; group 3 consisted of 10 patients with symptoms with a depressed resting echo peak Vcf which remained subnormal with exercise. Subsequent cardiac catheterisation disclosed normal ejection fractions in patients in group 1, borderline ejection fractions in those in group 2, and reduced ejection fractions in those in group 3. Echocardiographic assessment of left ventricular performance during supine isotonic exercise may provide a simple noninvasive method for the early detection of left ventricular dysfunction in symptom free patients with aortic regurgitation.     

Concordance between Doppler and pulsed-wave Doppler tissue imaging in estimation of the degree of left ventricular dysfunction and correlating it to the degree of chronic obstructive pulmonary disease

Objective

As a consequence of leftward shift of the interventricular septum and of pericardial restraint, related to the degree of right ventricular dilation, alveolar hypoxia and related pulmonary vascular changes, left ventricular function is influenced by chronic obstructive pulmonary disease (COPD). The aim of this study was to assess the prevalence of echocardiographic abnormalities by conventional echocardiography and Doppler tissue imaging (DTI) in COPD patients according to the degree of disease severity.

Methods

We enrolled forty consecutive patients with COPD and twenty matched control. Twenty of the patients were suffering from mild form of COPD, twenty were suffering from severe form of COPD as decided by pulmonary function test and arterial blood gases and twenty apparently healthy non COPD control persons were subjected to echocardiographic assessment to left ventricular diastolic and systolic functions by conventional echocardiography and DTI at the mitral annulus.

Results

There were no significant statistical difference between the three groups as regards the age and the gender. There were significant statistical differences between the patients and the control as regards the diastolic functions of the left ventricle. E and A waves obtained by conventional Doppler and by DTI showed significant statistical difference between mild, severe forms of COPD and control subjects. The degree of diastolic dysfunction increased significantly with increase of the severity of COPD.

Conclusion

Left ventricular diastolic function is significantly affected in patients with COPD and the degree of affection is related to the severity of COPD.     

Right ventricular diastolic dysfunction in arterial systemic hypertension: analysis by pulsed tissue Doppler.

AIMS: This study analyses right ventricular longitudinal function in arterial systemic hypertension by pulsed tissue Doppler. METHODS AND RESULTS: Thirty normotensives and 30 hypertensives, free of cardiac drugs, underwent standard Doppler echocardiography and pulsed tissue Doppler of right ventricular lateral tricuspid annulus and left ventricular lateral mitral annulus. By tissue Doppler, systolic and diastolic measurements were obtained. Hypertensives had higher left ventricular mass and impaired Doppler diastolic indexes, without changes of global systolic function. Tissue Doppler showed reduction of right ventricular E/A ratio and prolongation of relaxation time in comparison with controls (both P<0.00001). In the overall population, the length of tissue Doppler derived right ventricular relaxation time was positively related to right ventricular anterior wall thickness while right ventricular E/A ratio was positively related to E/A ratio of left ventricular mitral annulus (both P<0.00001). These relations remained significant even after adjusting for clinical and echocardiographic confounders by separate multivariate models. CONCLUSIONS: Arterial systemic hypertension is associated to right ventricular longitudinal diastolic dysfunction. This dysfunction involves the prolongation of active relaxation, which is independently associated with the degree of right ventricular hypertrophy and the impairment of passive wall properties, which is mainly due to ventricular interaction occurring under left ventricular pressure overload conditions.     

Quantification of global left ventricular systolic dysfunction in patients with coronary artery disease by pulsed Doppler tissue imaging: the value of mitral annulus time intervals

BACKGROUND: Mitral annulus systolic velocity measured by Doppler tissue imaging (DTI) offers an alternate method for assessment of global left ventricular systolic function. However, there has been no study correlating mitral annulus systolic time intervals with left ventricular ejection fraction (LVEF). METHODS: Patients with angina pectoris (AP, 16 cases) and prior myocardial infarction (MI, 34 cases) were studied by pulsed DTI. Sixteen age-matched normal subjects served as controls. The septum, lateral, anterior, and inferior walls of the mitral annulus were selected for DTI sampling. Time to peak of the systolic mitral annular wave (TS) and regional preejection period (PEP) were measured. RESULTS: PEP and TS were significantly longer in the MI group than that in the control and the AP groups. Both PEP and TS at all the annular sites and their two-site averages had significantly negative correlations with LVEF (r =-0.62 to -0.68 and -0.49 to -0.62; P < 0.001, respectively). CONCLUSION: PEP and TS as measured by pulsed DTI may be promising indexes for the quantitative assessment of global left ventricular systolic dysfunction in patients with coronary artery disease.     

Detection of exercise induced changes in left ventricular performance by Doppler echocardiography.

A study was performed to test the hypothesis that Doppler echocardiographic measurement of ascending aortic blood flow can detect exercise induced changes in left ventricular performance during exercise in patients suspected of having ischaemic heart disease. Acceleration and peak velocity of flow and stroke volume were determined by non-imaging Doppler echocardiography in the suprasternal notch in 38 patients as they underwent simultaneous exercise radionuclide ventriculography. The patients were divided into four groups: group 1 had resting ejection fractions greater than or equal to 50% and increased their ejection fractions greater than or equal to 5% during exercise; group 2 had resting ejection fractions of greater than or equal to 50% but the ejection fraction either fell or rose less than 5% during exercise; group 3 had resting ejection fractions less than 50% but the ejection fraction rose greater than or equal to 5% during exercise; and group 4 had resting ejection fractions less than 50% and the exercise ejection fraction either fell or rose less than 5% during exercise. Acceleration, velocity, and stroke volume all rose significantly during exercise in group 1. Acceleration also increased in group 2 but to a lesser extent; velocity and stroke volume did not increase. In group 3 acceleration and velocity increased but to a lesser extent than in group 1; stroke volume did not increase. In group 4 velocity increased slightly during exercise but acceleration and stroke volume were unchanged. Doppler echocardiography thus appears capable of detecting exercise induced changes in left ventricular performance and can identify normal and abnormal responses, as defined by radionuclide ventriculography.