<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.     

The role of N terminal pro-brain natriuretic peptide in the evaluation of left ventricular diastolic dysfunction: correlation with echocardiographic indexes in hypertensive patients

The utility of N-Terminal pro Brain Natriuretic Peptide (NT-proBNP) and Brain Natriuretic Peptide (BNP) for detecting left ventricular (LV) diastolic dysfunction in hypertensive patients without heart failure symptoms is unclear. In this study, we investigated the relation between NT-proBNP plasma levels and LV diastolic dysfunction in hypertensive patients without systolic dysfunction. Method: We studied 40 ambulatory patients (26 women, mean age 52 ± 5) with controlled hypertension. LV diastolic function was assessed with conventional Doppler, by means of mitral inflow and with tissue Doppler echocardiography by means of mitral annulus. The ratio of early diastolic transmitral E wave velocities to tissue Doppler mitral annulus early diastolic E' wave velocities (E/E′), was used to detect LV filling pressures. Patients were divided in three groups according to E/E′ ratios < 10 (group I), E/E′ ratios 'between' 10 and 15 (group II) and E/E′ ratios > 15 (group III). Plasma concentrations of NT-proBNP were measured by electro chemiluminescence's immunoassay. Results: The NT-proBNP blood levels were positively correlated significantly with E/E′ ratio (r = 0.80, P < 0.0001). Patients with elevated LV end diastolic pressure (LVEDP), defined as E/E′ > 15 (n = 8) had highest NT-proBNP (203 ± 75 pg/ml) levels. E/E′ 10 to 15 group (n = 16) had a mean NT-proBNP level of 71 ± 26 pg/ml, and those with E/E′ < 10 (n = 16) had 39 ± 20 pg/ml. A NT-proBNP value of 119 pg/ml had a sensitivity of 87%, a specificity of 100% for predicting E/E′ > 15. Conclusion: The assessment of the blood concentration of NT-proBNP is of potential value for identification of those patients with hypertension to detect early cardiovascular changes, especially LV diastolic dysfunction.     

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.     

Non-invasive evaluation of left ventricular filling pressures in patients with abnormal relaxation

The aim of the present study was to assess the ability of several echocardiographic and TDI (tissue Doppler imaging) parameters to predict an elevated LVEDP (left ventricular end-diastolic pressure) in patients with abnormal relaxation. Eighty-two consecutive patients presenting with an E /A ratio (ratio of early-to-late diastolic peak transmitral velocity) <0.9 scheduled for left heart catheterization underwent echocardiography, including TDI, and measurement of LVEDP using fluid-filled catheters. The difference in duration between P V (R) (retrograde peak in the pulmonary veins) and A (DeltaP V (R)- A ) was calculated from pulsed Doppler recordings. V (P) (propagation velocity of the early mitral inflow) was determined by colour M-mode. TDI measurements included E ' (early diastolic peak myocardial velocities near the lateral mitral annulus), MVG (the early diastolic transmyocardial velocity gradient of the posterior basal wall) and the PRT (peak relaxation time), determined as the time interval between aortic valve closure and peak E '. Fifty-six patients presented with LVEDP values <15 mmHg, whereas an LVEDP >15 mmHg was found in 26 patients. The index DeltaP V (R)- A showed a significant linear correlation with LVEDP ( r =0.7, P <0.001) and provided the highest predictive accuracy for the identification of LVEDP >15 mmHg [AUC (area under receiver operating characteristic curve)=0.83], followed by PRT (AUC=0.67), whereas other TDI-derived parameters failed to reach significance. In conclusion, DeltaP V (R)- A enabled the most accurate non-invasive estimation of LVEDP. A prolonged peak relaxation time was the only TDI-derived index that differed significantly between patient groups.     

Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals

Aim To study the effect of aging on and the relationship between echocardiographically estimated left ventricular (LV) filling pressure and estimated right ventricular (RV) systolic pressure among healthy normotensive individuals.Methods We analyzed 249 healthy individuals (aged 18–82 years, 52% men) with normal echocardiographic findings and reliably measurable tricuspid regurgitation gradients. Subjects with blood pressure >140/90 mmHg and/or LV hypertrophy were excluded. LV & RV dimensions and LV mass were measured with M-mode echocardiography. Atrial (A) volumes were determined with the area-length method. Diastolic function was assessed with transmitral Doppler and mitral annulus tissue Doppler. The ratio of transmitral early peak velocity to early diastolic mitral annulus velocity (E/E′) was used as estimation of LV filling pressure. The transtricuspid Doppler gradient was used to estimate RV end-systolic pressure.Results Even in normotensive individuals aging was accompanied by an increase in LV mass and LA dimensions and an increase in relaxation abnormalities. E/E′ increased with every decade: from 7.8 for age 18–35 years to 10.9 for age ≥75 years (p<0.0001) as did the transtricuspid gradient: from 18.3 mmHg for age 18–35 years to 25.8 mmHg for age ≥75 years (p<0.0001). Linear regression showed that estimated RV systolic pressure was independently predicted by age, LA volume, LV systolic function and E/E′.Conclusion Among normotensive healthy individuals both E/E′ and tricuspid regurgitation gradients increase significantly with aging. Moreover the E/E′ ratio was independently predicting the tricuspid regurgitation gradient. These findings support the need for further studies defining age specific normal values.     

Assessment of left ventricular diastolic function using color kinesis: differentiation between normal and pseudonormalized patterns

Purpose  Doppler examination of transmitral flow has been widely used to noninvasively assess left ventricular (LV) diastolic function. However, it has been demonstrated that transmitral flow velocity is dependent on LV relaxation and left atrial pressure. Increases in left atrial pressure compensate for the effects of impaired LV relaxation, frequently resulting in a “pseudonormalization” of the transmitral flow pattern. The purpose of this study was to assess whether analysis of diastolic color kinesis (CK) can be applied to differentiation between normal and pseudonormalized (PN) patterns of LV inflow. Methods  We studied 60 subjects with a ratio of early to late transmitral peak velocities (E/A) greater than 1.0 according to conventional Doppler echocardiography. All subjects simultaneously underwent measurement of the early diastolic mitral annular velocity (e′), which was measured by tissue Doppler imaging, and LV ejection fraction (EF), which was calculated by the modified Simpson method. Study subjects were classified into the following three groups according to the value of e′ and EF: (1) the normal group (e′ > 10 cm/s, EF > 60%), including 20 subjects (mean age 35 ± 10 years); (2) the PN1 group (e′ < 7 cm/s, EF > 50%), consisting of 20 patients [mean age 63 ± 11 years, 15 patients with hypertensive heart disease (HHD), 5 patients with aortic valve stenosis]; and (3) the PN2 group (e′ < 7 cm/s, EF < 50%), consisting of 20 patients (mean age 61 ± 17 years, 18 patients with dilated cardiomyopathy, 2 patients with HHD). Diastolic CK images were obtained for each subject from the LV midpapillary short-axis view. Analysis of CK diastolic images was performed using ICK software. The CK-diastolic index (CK-DI) was defined as the calculated LV segmental filling fraction during the first 30% of diastole, expressed as a percentage. The mean CK-DI was determined from the average CK-DI of six LV segments. Results  The mean CK-DI was 70.9% ± 6.5% in the normal group, 46.3% ± 10.4% in the PN1 group, and 36.3% ± 5.1% in the PN2 group. The mean CK-DI was significantly reduced in the PN1 and PN2 groups compared with the normal group (P < 0.0001). Although there was no difference in e′ (PN1 group: 4.6 ± 1.8 cm/s, PN2 group: 4.4 ± 1.7 cm/s) between the two pseudonormalized patient groups, the mean CK-DI was significantly reduced in the PN2 group compared with the PN1 group (P < 0.005). The reduction in mean CK-DI was seen not only in pseudonormalized patients with LV systolic dysfunction but also in those with preserved LV systolic function. Conclusion  The analysis of diastolic CK with ICK software is a useful method for detecting delayed early diastolic relaxation. We concluded that diastolic CK images may be applied to differentiating between normal and pseudonormalized patterns of LV inflow.     

Impact of mitral E/A ratio on the accuracy of different echocardiographic indices to estimate left ventricular end-diastolic pressure

The objective was to determine the influence of left ventricular (LV) inflow pattern on the accuracy of different echocardiographic indices for estimation of LV end-diastolic pressure (LVEDP). Echocardiography with color tissue Doppler imaging (TDI) and LVEDP measurements using fluid-filled catheters were performed in 176 consecutive patients on the same day. Mitral peak diastolic velocities (E, A) and the difference in duration between pulmonary venous retrograde velocity and mitral A-velocity (PV(R)-A) were recorded by pulsed Doppler. Propagation velocity of the early mitral inflow (V(P)) was assessed using color M-mode. Early diastolic longitudinal (E'(lat)) and radial (E'(radial)) velocities of mitral annulus were measured by TDI. Area under ROC curve (AUC) for prediction of elevated LVEDP (> or =15 mm Hg) was computed for each parameter. For E/A > or =1 (98 patients, 46 with elevated LVEDP), the AUC values were: PV(R)-A: 0.914; E/E'(lat): 0.780; E/E'(radial): 0.729; E/V(P): 0.712 (p < 0.001). When E/A <1 (78 patients, 26 with elevated LVEDP), only PV(R)-A reached statistical significance (AUC = 0.893, p < 0.001). The conclusions were: PV(R)-A enabled the most accurate noninvasive estimation of LVEDP irrespective of LV filling profile and combined indices E/V(P), E/E'(lat) and E/E'(radial) represent more feasible alternatives for patients with mitral E/A-1.     

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.     

Reduced left ventricular relaxation velocity after acute myocardial infarction

Diastolic left ventricular function is usually described using Doppler recording of the early to atrial (E/A) ratio. However, because of pseudonormalization in patients with moderately impaired diastolic function, the E/A ratio does not allow a meaningful comparison between a group of patients with varying degrees of dysfunction, e.g. after acute myocardial infarction (AMI), and a group of healthy control subjects. In this study, diastolic function was assessed using the E/A ratio, deceleration time of early mitral inflow and maximal longitudinal relaxation velocity. The relaxation velocity was measured using echocardiographic M-mode recording of mitral annulus motion. Mitral annulus motion was recorded in four- and two-chamber views. Relaxation velocities were measured in the septal, lateral, anterior and posterior parts of the mitral annulus and the mean value (RV_m) was calculated. Twenty-two consecutive patients were investigated 3–21 days after first transmural AMI. Twenty-two healthy subjects of similar age served as a control group. The group of patients with AMI had an RV_m of 40·9 ± 15·4 mm s^?1 compared with 68·5 ± 12·4 mm s^?1 in the control group (P<0·0001). In contrast, the E/A ratio, deceleration time and heart rate did not differ significantly between the two groups. The results suggest that maximal longitudinal relaxation velocity is a simple and appropriate measure of diastolic function in patients with transmural AMI.     

Evaluation of left ventricular diastolic function using color kinesis

Purpose Color kinesis (CK) is a real-time echocardiographic technique based on acoustic quantification that yields regional and global information by tracking and color-encoding endocardial motion. The aim of this study was to determine the feasibility and usefulness of diastolic CK images with ICK software to objectively assess global and regional left ventricular (LV) diastolic function. Accordingly, diastolic properties obtained from CK images were compared with conventional Doppler echocardiographic indices. Methods We studied 56 subjects who underwent echocardiographic evaluation in our laboratory for assessment of cardiac structure and function. Criteria for inclusion included the presence of normal sinus rhythm and adequate two-dimensional echocardiographic imaging. Exclusion criteria were (1) all types of arrhythmias, (2) pericardial effusion, (3) heart rates <55 or >90 beats/min, (4) abnormal interventricular septal motion caused by right ventricular pressure or volume overload, (5) moderate to severe mitral or aortic regurgitation, and (6) mitral valve stenosis. Using pulsed Doppler echocardiography, peak velocities during rapid filling (E) and atrial contraction (A) were measured, and the E/A ratio and deceleration time of the E wave velocity (DT) were calculated. The time-velocity integral (TVI) of the E wave (TVI-R), A wave (TVI-A), and rapid-filling fraction (TVI-R/TVI-R+TVI-A) was measured. The early diastolic mitral annular velocity (Ea) was measured by tissue Doppler. The 56 subjects were divided into the following three groups: (1) an impaired relaxation group consisting of 30 patients with normal ejection fraction and a mitral inflow pattern with a reduced E/A ratio (E/A < 1.0); (2) a pseudonormal group consisting of 18 patients with a mitral inflow pattern with an increased E/A ratio (E/A > 1.0), an increased E/Ea ratio (E/Ea 10), and no shortened DT (≧140 ms) [patients with hypertrophic cardiomyopathy (HCM, n = 8), dilated cardiomyopathy (DCM, n = 8), and aortic valve stenosis (n = 2) were included in this group); and (3) a restrictive group consisting of eight patients with a mitral inflow pattern with an increased E/A ratio (E/A >1.5), an increased E/Ea ratio (E/Ea ≧10), and a shortened DT (<140 ms) [patients with DCM (n = 5) and HCM (n = 3) were included in this group]. As a control group, 20 normal subjects (30 ± 18 years) were selected on the basis of having high-quality echocardiographic images. Diastolic CK images were obtained from the LV midpapillary short-axis view. The analysis of CK diastolic images was performed by using ICK software. The CK-diastolic index (CK-DI) was defined as the degree of LV segmental expansion during the first 30% of diastole, expressed as a percentage. The mean CK-DI was calculated from the average CK-DI of six LV segments. Results No relationship was observed between mean CK-DI and rapid-filling fraction in any of the study subjects (r = −0.092, P > 0.2). Mean CK-DI was significantly lower in the restrictive group (34.2% ± 4.3%) compared with the normal group (70.6% ± 7.4%), the impaired relaxation group (50.5% ± 7.7%), and the pseudonormal group (42.3% ± 7.5%). The reduction of mean CK-DI was found to be associated with the progression of LV diastolic dysfunction. Conclusion We conclude that the analysis of diastolic CK by using ICK software is a useful technique that can be applied to quantitative evaluation of LV global diastolic function.     

Evaluation of left ventricular diastolic function when mitral E and A waves are completely fused: role of assessing mitral annulus velocity.

Mitral inflow parameters have been used most widely in the evaluation of left ventricular (LV) diastolic function. However, when the mitral E and A waves are completely fused, mitral inflow parameters cannot provide information about the LV diastolic function. LV filling pressure, mitral inflow, mitral annulus velocity, and tau (tau) were measured in 59 patients with sinus rhythm when mitral E and A waves were completely fused with right atrial pacing. When mitral E and A waves were completely fused, tau correlated with the peak fused mitral annulus velocity (r = -0.60, P <.001), and peak fused mitral annulus velocity of less than 12.5 cm/s best discriminated prolonged (>/=50 ms) from normal tau, with a sensitivity of 78% and specificity of 69%. The peak fused mitral inflow velocity to peak fused mitral annulus velocity ratio correlated with LV filling pressure (r = 0.62, P <.001). A ratio of at least 8, could predict elevated LV filling pressure (>/=15 mm Hg) with a sensitivity of 65% and specificity of 74%. In conclusion, even when mitral E and A waves are completely fused, mitral annulus velocity can be used in the evaluation of LV diastolic function.     

Diagnosis of left ventricular diastolic dysfunction by Doppler echocardiography

Left ventricular(LV) diastolic dysfunction with preserved LV systolic function is common among patients with hypertension, especially with LV hypertrophy. Doppler echocardiography is one of the most useful clinical tools for the evaluation of diastolic function. Mitral inflow and pulmonary venous flow velocities are used not only for the assessment of diastolic function but also for predicting prognosis. Recently, tissue Doppler echocardiography has been also applied to evaluate diastolic function. Accurate assessment of diastolic function has been demonstrated by measuring both mitral annulus and mitral inflow velocity. In this article, We review the diagnosis of diastolic dysfunction by Doppler echocardiography using mitral inflow velocity, pulmonary venous flow velocity and mitral annulus velocity measured by tissue Doppler imaging.     

Doppler tissue imaging and catheter-derived measures are not independent predictors of rejection in pediatric heart transplant recipients

The purpose of the study is to determine the association of Doppler Tissue Imaging (DTI) and catheter-derived measures with rejection in pediatric heart transplant (PHT) recipients and to determine any correlation between DTI and catheter-derived measurements. Sixty echocardiograms were prospectively performed in 37 PHT recipients at the time of surveillance cardiac biopsy. During right-heart cardiac catheterization, sequential pressures of the right heart and pulmonary capillary wedge pressures (PCWP) were measured. DTI was performed to obtain peak systolic (S’), early (E’) and late (A’) diastolic velocities (cm/s) at tricuspid annulus, septum and mitral annulus. Septal S’ and tricuspid annular A’ were associated with rejection, but had low sensitivity and specificity. Elevated lateral mitral E/E’ did not predict rejection. The mean pulmonary capillary wedge pressure (PCWP) and cardiac index were similar in those with and without rejection. The lateral mitral and septal E/E’ did not correlate with PCWP. Some DTI-derived measures were altered during rejection, but were not clinically useful predictors of rejection. Catheter-derived measures were not significantly altered during rejection and did not correlate with DTI-derived measures. None of these measures can replace the current practice of performing cardiac biopsy for surveillance of rejection.     

Detection of high-burden coronary artery disease by exercise-induced changes of the E/E’ ratio

To investigate whether exercise-induced changes of the E/E’ average ratio can detect high-burden coronary artery disease (CAD) in patients with chest pain and normal left ventricular (LV) systolic function. The study population consisted of 359 patients admitted for chest pain (59.8 ± 9.8 years, 75% male). Patients underwent exercise echocardiography, scintigraphy and coronary angiography. The average of the lateral and septal ratios of early diastolic transmitral velocity to early diastolic tissue velocity (E/E’) at baseline and immediately after exercise was calculated. Exercise induced wall motion abnormalities were also calculated. Coronary angiography showed flow limiting CAD in 238 patients (66%). The exercise-induced changes of E/E’ average ratio had a sensitivity of 87.3% and a specificity of 75.2% for detection of flow limiting CAD, whereas myocardial scintigraphy showed 79.2% sensitivity and 80.1% specificity and exercise induced wall motion abnormalities had a sensitivity of 74.3% and a specificity of 66.9%. Likelihood ratio chi square showed an incremental value of the exercise-induced changes of E/E’ average ratio over regional perfusion technique (from 121.37 to 194.15, P < 0.001) and over wall motion abnormalities (from 57.03 to 146.50, P < 0.001). The exercise-induced change of the E/E’ average ratio detects flow limiting CAD in patients with chest pain and normal LV systolic function showing an incremental value over regional perfusion technique and wall motion abnormalities.     

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.     

定量组织速度成像测量二尖瓣环运动速度

目的　应用定量组织速度成像测量二尖瓣环运动速度评价扩张型心肌病患者左室舒张功能。方法　定量组织速度成像测量 14例正常人和 14例扩张型心肌病患者二尖瓣环 6个节段 (后间隔和侧壁、前间隔和后壁、前壁和下壁 )舒张早期峰值速度Ve、左房收缩期峰值速度Va ,计算Ve Va ;多普勒超声心动图测量二尖瓣口血流快速充盈速度E峰、左房收缩充盈速度A峰 ,计算E A值。结果　正常人和扩张型心肌病患者两组间E A无显著统计学差异 ,而扩张型心肌病组二尖瓣环平均Ve Va、平均Ve较正常组显著减低 (Ve Va :0 .89± 0 .11vs 1.76± 0 .76,P =0 .0 0 1;Ve :-4 .79± 2 .2 2vs -8.42± 2 .2 7,P<0 .0 0 0 1) ;正常组中二尖瓣环平均Ve Va与E A显著相关 (r =0 .63 ,P =0 .0 0 8) ,而扩张型心肌病组二尖瓣环平均Ve Va与E A无显著相关。结论　扩张型心肌病患者二尖瓣口血流频谱表现为假性正常化 ,定量组织速度成像测量二尖瓣环运动速度可准确评价其左室舒张功能。     

超声心动图根据主动脉瓣和/或二尖瓣反流压差评估左心腔压力价值的探讨

目的采用血浆脑钠素(BNP)和二尖瓣血流频谱舒张早期速度与二尖瓣环组织多普勒舒张早期速度比值(E/Ea)等指标作参照,探讨超声心动图根据主动脉瓣和二尖瓣反流压差评估左心腔压力的临床实用价值。方法研究对象为118例超声心动图存在轻度二尖瓣反流和/或主动脉瓣反流患者(GTOTAL)。其中31例测定了BNP(GBNP),余87例未检测BNP(NGBNP)。常规超声心动图检查记录射血分数(EF),左心房前后径(LAD),常规检测右上肢肱动脉血压(收缩压,Ps;舒张压,Pd)、主动脉瓣反流频谱舒张末期速度(VAR)、二尖瓣反流频谱最大速度(VMR)。根据公式计算:左心室舒张末期压力(LVEDP)=Ps-4VAR2;左心房压力(LAP)=Ps-4VMR2。分析各组BNP、E/Ea、EF以及LAD与LAP和LVEDP的相关性。结果方差齐性检验和一致性检验显示各组间患者分布状态无显著差异(P>0.05)。各组LAP与BNP、E/Ea、LAD和EF均呈中度相关;各组LVEDP与BNP、E/Ea、LAD和EF的相关性差。结论利用二尖瓣反流测算LAP有一定实用价值。但利用主动脉瓣反流测算LVEDP不能客观反映患者的病理生理状态。     

Diagnostic superiority of a combined assessment of the systolic and early diastolic mitral annular velocities by tissue Doppler imaging for the differentiation of restrictive cardiomyopathy from constrictive pericarditis

Background and aims  

Echocardiographic tissue Doppler imaging (TDI) has been proposed as diagnostic tool for the differentiation between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this study was a comprehensive TDI analysis of systolic (S′) and early diastolic (E′) velocities of the septal and lateral mitral annulus (MA) in patients (pts) with severe diastolic dysfunction caused either by CP or RCM.     

Left Ventricular Systolic and Diastolic Function in Patients With Apical Ballooning Syndrome Compared With Patients With Acute Anterior ST-Segment Elevation Myocardial Infarction: A Functional Paradox

OBJECTIVE: To compare left ventricular (LV) systolic and diastolic function in patients with apical ballooning syndrome (ABS) and those with acute myocardial infarction (AMI) using 2-dimensional Doppler echocardiography and strain rate imaging (SRI).PATIENTS AND METHODS: We prospectively enrolled patients with newly diagnosed AMI and ABS who had akinetic apical walls. Both 2-dimensional Doppler echocardiography and SRI were performed on hospital day 1 or within 24 hours of primary percutaneous coronary intervention.RESULTS: Twenty-four patients with AMI and 13 patients with ABS (mean ± SD age, 63±15 vs 73±12 years; P=.03) were prospectively enrolled in the study from October 3, 2005 through July 12, 2006. The mean ± SD LV end-diastolic volume was larger (58.1±9.1 vs 45.2±10.6 mL/m²; P<.001) and the mean ± SD LV ejection fraction was lower (35%±6% vs 43%±9%; P=.006) in patients with ABS compared with patients with AMI. The early diastolic mitral annular velocity was similar (0.06±0.02 vs 0.06±0.02 m/s; P=.85) in both groups, but the ratio of early diastolic mitral valve inflow velocity to early diastolic mitral annulus velocity was higher in patients with AMI than in patients with ABS (16.3±6.9 vs 12.2±3.2; P=.05). The systolic strain rate was decreased at the apex in both groups (P=.98). Both the early diastolic strain rate of the apex (0.64±0.24 vs 0.48±0.30 s^-1; P=.04) and the postsystolic shortening index of the apex (61%±15% vs 45%±23%; P=.006) were higher in the patients with ABS than in those with AMI. However, early diastolic SR was higher in the akinetic apical walls of patients with AMI with recovery than those with no recovery (0.64±0.35 vs 0.43±0.25 s^-1; P=.04) and was similar between akinetic apical walls of patients with AMI with recovery and the akinetic apical walls of ABS.CONCLUSION: Compared with patients with AMI, those with ABS showed the functional paradox of worse initial LV systolic function with larger LV size but better LV diastolic function. The early systolic strain rate and postsystolic shortening were greater in patients with ABS than in those with AMI; hence, these measurements can be helpful in distinguishing ABS from AMI and in detecting myocardial viability.ABS = apical ballooning syndrome; AMI = acute myocardial infarction; CAG = coronary angiography; E = early diastolic mitral valve inflow velocity; Ea = early diastolic mitral annulus velocity; E/Ea = ratio of early diastolic mitral valve inflow velocity to early diastolic mitral annulus velocity; ECG = electrocardiography; LV = left ventricular; LVEF = LV ejection fraction; PCI = percutaneous coronary intervention; SR = strain rate; SRI = SR imaging; STEMI = ST-segment elevation myocardial infarction; WMSI = wall motion score indexThe clinical presentation of apical ballooning syndrome (ABS) mimics that of acute myocardial infarction (AMI). Both conditions are characterized by acute onset of chest pain, electrocardiographic (ECG) changes, and increases in cardiac enzymes and apical or midventricular wall motion abnormalities, which often make it difficult to differentiate ABS from AMI, especially during the acute stage. However, management and prognosis of these conditions are different because left ventricular (LV) wall motion abnormalities and LV systolic function in patients with ABS almost always recover in a period of days to weeks compared with patients with AMI, who frequently experience residual wall motion abnormalities even after timely acute reperfusion therapy.The early improvement in LV wall motion abnormalities in patients with ABS is consistent with myocardial viability despite significant LV wall motion abnormalities during the initial event. Therefore, we speculate that ABS is a good clinical model of viable apical myocardium, and comparison of LV systolic and diastolic function between patients with ABS and those with AMI can provide a unique opportunity to assess systolic and diastolic parameters associated with myocardial viability.Strain rate imaging (SRI) is a new tissue Doppler-based method that can quantify regional myocardial deformation.¹ Early experimental and clinical studies have shown that SRI can not only differentiate abnormal from normal myocardial contractility during the initial phase of an infarction but can also demonstrate subsequent recovery of transient ischemia.^1-5 The objectives of this study were to compare 2-dimensional Doppler echocardiographic and SRI features of patients with ABS and AMI and to evaluate systolic and diastolic parameters associated with myocardial viability.     

多普勒组织成像评价高血压病患者左室舒张功能

目的　探讨应用多普勒组织成像 (DTI)技术检测二尖瓣环运动速度评估原发性高血压病左室舒张功能的应用价值。方法　应用DTI技术 ,对 5 6例原发性高血压病患者和 5 0例正常对照者二尖瓣环运动速度进行测定 ,并与常规多普勒超声心动图检查结果对照分析。结果　与正常组相比 ,高血压病患者收缩期DTI速度峰值 (S)差异无显著性意义 ,舒张早期DTI速度峰值 (Ve)显著减低 (P <0 .0 5 ) ,舒张晚期DTI速度峰值 (Va)无显著变化 ,舒张早期与舒张晚期DTI速度峰值的比值 (Ve Va)显著减低 (P <0 .0 5 )。Ve Va值与二尖瓣血流频谱E A值之间存在高度相关性。结论　DTI技术检测二尖瓣环舒张期运动速度参数可用于无创评价原发性高血压病左室舒张功能。