Triphasic diastolic pattern and delayed timing of myocardial relaxation identify dynamic changes of left ventricular filling pressure

The case reported concerns a woman with hypertensive emergency, showing triphasic diastolic pattern with mid-diastolic velocity both at transmitral inflow and at pulsed tissue Doppler-derived septal/lateral mitral annulus. In addition, the time from EKG R wave peak to annular early diastolic velocity (Em) onset was longer than the time occurring between R peak and transmitral E velocity. E/Em ratio was 14.6 and left atrium enlarged. After blood pressure fall and clinical stabilization, the triphasic diastolic patterns were again observed. However, the timing of early diastolic velocity was the same at mitral inflow and annular tissue Doppler. E/Em ratio and left atrial volume were reduced. The present report highlights the additional value of pulsed tissue Doppler to detect alteration of diastolic properties and dynamic changes of left ventricular filling pressure.     

IVRT'/IVRT index is a useful tool for detection of elevated left ventricular filling pressure in patients with preserved ejection fraction

OBJECTIVE: Deterioration of active relaxation results in prolongation of isovolumteric relaxation time (IVRT), however, when left ventricular filling pressure elevates, mitral valve opens earlier and IVRT shortens. This shortening is not seen when IVRT is measured with tissue Doppler imaging (IVRT'). Then, IVRT' prolongs with the deceleration of active relaxation independent of left ventricular filling pressure. We hypothesized that IVRT' reflects the relaxation rate, thus, the ratio of IVRT' to IVRT may possibly detect left ventricular filling pressure elevation. METHODS: The group of 39 subjects (aged 64 +/- 5 years) with preserved ejection fraction (EF > 50%) underwent combined echocardiographic and hemodynamic examinations. Echocardiographic parameters of mitral inflow and mitral annular motion were correlated with invasive indices of left ventricular relaxation and filling pressure. RESULTS: Time constant of isovolumetric pressure decline (tau) correlated closely with IVRT' (r = 0.73, P < 0.001) but not with early diastolic velocity of mitral annulus (E') (r =-0.207, P = 0.206). The best parameter correlating with M-LVDP was IVRT'/IVRT (r = 0.694, P < 0.001, M-LVDP = 7.7 x IVRT'/IVRT + 5.1). A weaker relation was also noted between the ratio of early mitral peak inflow velocity to early diastolic velocity of mitral annulus (E/E') and M-LVDP (r = 0.469, P < 0.001). The relationships between standard Doppler parameters and left ventricular diastolic pressures were uniformly poor. CONCLUSIONS: The study demonstrated that IVRT' may serve as a surrogate of left ventricular active relaxation. IVRT'/IVRT index may be applied to estimate left ventricular filling pressure.     

Relation of left ventricular diastolic function as measured by echocardiography and pulmonary capillary wedge pressure to rejection in young patients (< or = 31 years) after heart transplantation

To investigate the association of catheter-derived and newer echocardiographically derived measures of diastolic function with rejection in heart transplant recipients, 48 transplant recipients had Doppler and Doppler tissue imaging assessment along with catheter-measured pulmonary capillary wedge pressure (PCWP) at the time of endomyocardial biopsy. Of echocardiographic measures, propagation velocity (Vp), mitral E-wave velocity (E)/Vp, and E/annular mitral E-wave velocity (Em) were significantly associated with rejection (p <0.02), and an elevated PCWP was associated with rejection (p = 0.023) but with poor sensitivity. Weak but insignificant correlations with PCWP were found for E/Vp (r = 0.28) and E/Em (r = 0.37).     

Detection of a pseudonormal mitral inflow pattern: an echocardiographic and tissue Doppler study

OBJECTIVE: The aim of this study was to assess the ability of several echocardiographic and tissue Doppler imaging (TDI) derived parameters to improve the noninvasive diagnosis of a pseudonormal mitral inflow pattern. METHODS: Ninety-eight consecutive patients with age-related normal transmitral Doppler profile underwent echocardiography including TDI and measurement of left ventricular end-diastolic pressure (LVEDP) using fluid-filled catheters. Peak transmitral velocities were determined at rest (E, A) and during the strain phase of a Valsalva maneuver. The difference in duration between the pulmonary venous retrograde velocity and the transmitral A-velocity (PVR-A) was calculated from pulsed Doppler recordings. Propagation velocity of the early mitral inflow (VP) was determined by color M-mode. Early diastolic peak mitral annulus velocities (E') and the early diastolic transmyocardial velocity gradient of the posterior basal wall (MVG) were obtained by TDI. RESULTS: Fifty-two patients presented with normal diastolic function (group I: LVEDP9.5 +/- 3 mm Hg, E/A1.1 +/- 0.19), while pseudonormalization, defined as LVEDP 15 mm Hg and E/A > 0.9, was found in 46 patients (group II: LVEDP23 +/- 7 mm Hg, E/A1.43 +/- 0.83). The coefficient of linear correlation (r) and the area under ROC - curve (AUC) to predict LVEDP values 15 mm Hg were maximal for the index PVR-A (AUC = 0.92, r = 0.77), followed byE/E' (AUC = 0.80, r = 0.46), MVG (AUC = 0.65, r = 0.33) and E/VP (AUC = 0.69, r = 0.30), P < 0.01, whereas the decrease in E/A ratio during Valsalva maneuver failed to reach significance. Similar results were observed when echocardiographic parameters were used to estimate the left ventricular diastolic pressure before atrial contraction. CONCLUSIONS: PVR-A enabled the most accurate estimation of LVEDP. TDI-derived indices E/E' and MVG are also reliable alternatives superior to the classical Valsalva maneuver to detect a pseudonormal transmitral Doppler profile.     

Usefulness of the pulmonary arterial systolic pressure to predict pulmonary arterial wedge pressure in patients with normal left ventricular systolic function

Tissue Doppler imaging combined with transmitral Doppler permits estimation of pulmonary artery wedge pressure (PAWP) in many, but not all, patients, whereas pulmonary artery systolic pressure (PASP) and cardiac output (time-velocity integral method) are routinely measured. It was hypothesized that simple Doppler echocardiographic measurements could be used to estimate PAWP in many patients by rearranging the equation for pulmonary vascular resistance ([mean pulmonary artery pressure - (left atrial pressure/cardiac output)] x 80). Data from 69 patients (mean age 59 +/- 15 years) were reviewed, including cardiac output, transmitral mitral E wave velocity, and lateral tissue Doppler imaging mitral annular early diastolic velocity. PAWP was determined in the 2 ways of (1) measured (PAWPm) using the regression equation PAWPm = 1.91 + (1.24 * transmitral mitral E wave velocity/mitral annular early diastolic velocity) developed and validated by Nagueh, and (2) using a nomogram that we developed to predict PAWP when cardiac output and PASP were known. Moderately strong correlation was found between PASP and PAWPm (r = 0.73), and this correlation improved when excluding patients with pulmonary or liver disease and restricting cardiac output to 3.5 to 6.0 L/min (physiologic range; r = 0.81). Furthermore, the relation between PAWPm and PASP allowed for discrimination of high versus low PAWP: 36 of 37 patients with PASP < or =30 mm Hg had PAWPm < or =15 mm Hg (sensitivity 97%, specificity 47%). Conversely, 9 of 9 patients with PASP > or =40 mm Hg had PAWPm > or =12 mm Hg (sensitivity 100%, specificity 70%). Predicted PAWP correlated well with PAWPm (r = 0.63) and improved when patients with liver or pulmonary disease were excluded (r = 0.83). In conclusion, PASP strongly correlated with PAWP, and this principle can be exploited to rapidly detect patients with low or high PAWP.     

Assessment of left ventricular function by Doppler tissue imaging in patients with atrial fibrillation following acute myocardial infarction

AIMS: We studied tissue Doppler parameters in patients with atrial fibrillation following acute myocardial infarction, and their relation to P wave durations and P dispersion. METHODS: Echocardiographic examination was performed in 84 consecutive patients with first anterior acute myocardial infarction. In addition to other conventional echocardiographic parameters, the peak systolic (Sm), early diastolic (Em) and late diastolic (Am) velocities were obtained at the lateral corner of the mitral annulus by pulsed wave tissue Doppler. The Em/Am ratio and the ratio of early diastolic mitral inflow velocity to Em (E/Em), which is a marker of diastolic filling pressure, were calculated. Electrocardiogram was recorded from all patients on admission; P wave measurements were also performed. RESULTS: Atrial fibrillation occurred in 20 (23.8%) of 84 patients. The patients with atrial fibrillation had significant reduction of Em (5.6+/-1.5 vs. 8.7+/-2.7 cm/s, p < 0.001), Em/Am (0.61+/-0.27 vs. 0.84+/-0.23, p = 0.001) and Sm (7.1+/-1.0 vs. 8.3+/-1.9 cm/s, p < 0.001) values compared with those without. The E/Em ratio (14.45+/-4.62 vs. 7.47+/-2.79, p < 0.001), P maximum (102+/-11 vs. 95+/-11 ms, p = 0.02) and P dispersion (35+/-7 vs. 26+/-7 ms, p < 0.001) were significantly higher in patients with atrial fibrillation than in those without. In all patients, P dispersion showed significant correlation with Em (r = -0.33, p = 0.002), Sm (r = -0.40, p < 0.001) and E/Em (r = 0.32, p = 0.003). When E/Em > or = 10 was used as cutpoint, atrial fibrillation could be predicted with a sensitivity of 90%, and a specificity of 84%. CONCLUSIONS: The patients with atrial fibrillation following acute myocardial infarction have reduced systolic and diastolic mitral annular velocities and increased E/Em ratio, P maximum and P dispersion values compared to those without. P dispersion is correlated with systolic and diastolic left ventricular function after acute myocardial infarction. The E/Em ratio appears to be a useful parameter for assessing the risk of atrial fibrillation occurrence after anterior acute myocardial infarction.     

Improvements in left ventricular diastolic function after cardiac resynchronization therapy are coupled to response in systolic performance.

OBJECTIVES: To determine the short-term effects of cardiac resynchronization therapy (CRT) on measurements of left ventricular (LV) diastolic function in patients with severe heart failure. BACKGROUND: Cardiac resynchronization therapy improves systolic performance; however, the effects on diastolic function by load-dependent pulsed-wave Doppler transmitral indices has been variable. METHODS: Fifty patients with severe heart failure were evaluated by two-dimensional Doppler echocardiography immediately prior to and 4 +/- 1 month after CRT. Measurements included LV volumes and ejection fraction (EF), pulsed-wave Doppler (PWD)-derived transmitral filling indices (E- and A-wave velocities, E/A ratio, deceleration time [DT], diastolic filling time [DFT], and isovolumic relaxation time). Tissue Doppler imaging was used for measurements of systolic and diastolic (Em) velocities at four mitral annular sites; mitral E-wave/Em ratio was calculated to estimate LV filling pressure. Color M-mode flow propagation velocities were also obtained. RESULTS: After CRT, LV volumes decreased significantly (p < 0.001) and LVEF increased >5% in 28 of 50 patients (56%) and were accompanied by reduction in PWD mitral E-wave velocity and E/A ratio (both p < 0.01), increased DT and DFT (both p < 0.01), and lower filling pressures (i.e., E-wave/Em septal; p < 0.01). Patients with LVEF response < or =5% after CRT had no significant changes in measurements of diastolic function; LV relaxation (i.e., Em velocities) worsened in this group. CONCLUSIONS: In heart failure patients receiving CRT, improvement in LV diastolic function is coupled to the improvement in LV systolic function.     

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.     

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.     

Feasibility of tissue magnetic resonance imaging: a pilot study in comparison with tissue Doppler imaging and invasive measurement

OBJECTIVES: This research was intended to determine the feasibility of tissue magnetic resonance (MR) imaging in comparison with tissue Doppler imaging and its potential implications for the estimation of filling pressure, in comparison with invasive measurement. BACKGROUND: Evaluation of diastolic function using MR imaging is commonly confined to the study of transmitral flow. However, transmitral flow is unreliable for the estimation of left ventricular (LV) filling pressures in hypertrophy and normal systolic function. Normalizing early mitral velocity (E) for the influence of myocardial relaxation by combining E with early diastolic mitral septal tissue velocity (Ea) provides better Doppler estimates of filling pressures. METHODS: Eighteen patients with hypertensive heart disease (LV mass index: 114 +/- 21 g/m(2)), absence of valvular regurgitation, and with normal or mildly reduced systolic function (LV ejection fraction: 57.6 +/- 6.5%) referred for cardiac catheterization, underwent consecutive measurement of mitral flow and septal tissue velocities with phase-contrast MR and Doppler. These data were compared with mean pulmonary capillary wedge pressure (PCWP). RESULTS: There was a strong relation between MR (11.6 +/- 4.3) and Doppler-assessed (12.1 +/- 3.5) E/Ea (95% confidence interval of -1.5 to 0.5) (r = 0.89, p < 0.0001). In addition, E/Ea related strongly to invasively measured PCWP (MR: r = 0.80, p < 0.0001 and Doppler: r = 0.85, p < 0.0001). CONCLUSIONS: Tissue MR imaging is a feasible method to assess Ea. Combining E and Ea allowed similar estimation of filling pressure by MR and Doppler, in good agreement with invasive measurement. The potential confounding effect of valvular regurgitation needs further study.     

Validation of six noninvasive Doppler methods for the assessment of left ventricular filling pressure

OBJECTIVES: The aim of this study was to determine the accuracy of six noninvasive Doppler methods for assessing invasively derived left ventricular diastolic pressure (LVDP). Background: To date, no studies have evaluated which of the various available Doppler methods are most reliable in determining LVDP in a consecutive patient population with different cardiac diseases. METHODS: LVDP was estimated by the following Doppler methods (M): (1) M1-the peak mitral regurgitant flow velocity (peak MR), (2) M2-the mitral regurgitant velocity at the time of aortic valve opening (MRAVO), (3) M3-the aortic regurgitant end-diastolic flow velocity (ARED), (4) M4-the ratio of the transmitral to mitral annular early diastolic velocity (ETM/EDTI), (5) M5-a transmitral flow velocity regression equation (RegrTM), and (6) M6-the difference of pulmonary venous and transmitral A wave duration (APV - ATM duration). For M1-M3, sphygmomanometric blood pressure was used to calculate LVDP. RESULTS: In 101 patients, the regression coefficient, standard error of estimate, and mean difference with confidence limits between Doppler and catheter-derived measurements were as follows: M1 (n = 46): r = 0.81 (P < 0.0001), 4.3 mmHg and 3.7 +/- 12.0 mmHg; M2 (n = 47): r = 0.79 (P < 0.0001), 5.4 mmHg and 1.1 +/- 11.2 mmHg; M3 (n = 20): r = 0.64 (P = 0.002), 7.8 mmHg and 4.6 +/- 17.6 mmHg; M4 (n = 50): r = 0.62 (P < 0.0001), 5.6 mmHg and 0 +/- 11.2 mmHg; M5 (n = 79): r = 0.24 (P = 0.03), 7.1 mmHg and - 0.1 +/- 16.8 mmHg; and M6 (n = 79): r = 0.22 (P = 0.05), 7.3 mmHg and 0 +/- 14.4 mmHg, respectively. CONCLUSIONS: The Doppler measurement of mitral regurgitant jets is most accurate method to estimate left ventricular filling pressure noninvasively.     

限制性心肌病患者血浆B 型利尿肽水平影响因素分析

目的探讨在限制性心肌病（RCM）患者中血浆B型利尿肽（BNP）的影响因素。方法入选20例经过组织活检确诊为RCM的患者。将临床、超声心动图和右心导管指标与血浆BNP水平进行相关性分析。结果 RCM患者血浆BNP水平为（792.3±1045.9）ng/L。相关性分析显示BNP与年龄、性别、心功能分级和药物治疗无显著相关;而与超声心动图左心室舒张功能指标,即二尖瓣血流峰值速度E/A比值（r=0.46）、二尖瓣E峰减速时间（r=-0.59）、等容舒张时间（r=-0.45）、组织多普勒成像二尖瓣环舒张早期速度（E′）峰值（r=-0.45）和E/E′比值（r=0.86）有显著相关性（P〈0.05）。BNP与右心导管测定的右心房压力（r=0.45）、右心室舒张末压力（r=0.56）和肺动脉楔压（r=0.46）显著相关（P〈0.05）。多因素回归分析显示二尖瓣E/E′是BNP唯一的独立相关因素（β=0.69,P〈0.05）。结论 RCM患者血浆BNP水平升高,而且与多普勒超声心动图的左心室舒张功能指标以及右心导管测定的右心室舒张压力显著相关。     

Left ventricular diastolic function and endothelial function in patients with erectile dysfunction

The aim of this study was to assess left ventricular diastolic function and forearm endothelial function in patients with erectile dysfunction (ED) without overt cardiovascular disease. Forearm endothelial function and diastolic Doppler parameters, including tissue Doppler imaging, were studied in 32 men with ED and 27 age-matched, healthy, male control subjects. Left ventricular diastolic function in patients with ED and the relation between endothelium-dependent vasodilation and the Doppler parameters of left ventricular diastolic function, including tissue Doppler imaging, were assessed. Endothelium-dependent vasodilation (4.1+/-3.3% vs 9.7+/-4.2%, p<0.001) as well as the mitral inflow E velocity (0.66+/-0.17 vs 0.80+/-0.16 m/s, p=0.01), the E/A ratio (the ratio of mitral inflow E velocity to mitral inflow A velocity; 0.91+/-0.3% vs 1.22+/-0.26%, p<0.001), and the E/Em ratio (the ratio of mitral A-wave velocity to early diastolic velocity in the annulus derived by tissue Doppler imaging; 7.4+/-2.7% vs 6.6+/-1.6%, p=0.03) were smaller in the ED group than in the control group. Deceleration time (228.6+/-61.6 vs 192.9+/-44.6 ms, p=0.03) and isovolumetric relaxation time (112.8+/-18 vs 94+/-15.9 ms, p<0.001) were also prolonged in the ED group compared with the control group. The mitral E-wave velocity (r=0.40, p=0.022), the E/A ratio (r=0.40, p=0.027), and the E/Em ratio (r=-0.52, p= 0.003) were related to endothelium-dependent vasodilation by nivariate analysis. Only the E/Em ratio was correlated with endothelium-dependent vasodilation by multivariate analysis. In conclusion, this study indicates that endothelial function and left ventricular diastolic function are impaired in patients with ED without overt cardiovascular disease.     

Differences in echocardiographic assessment with standard Doppler and tissue Doppler imaging of left ventricular filling pressure in idiopathic and ischemic dilated cardiomyopathy

Background: In idiopathic and ischemic dilated cardiomyopathy (DCM) there are differences in left atrial and ventricular relaxation. We assessed the hypothesis of an influence of these dissimilarities in assessing left ventricular filling pressure (LVFP) in these two DCMs by standard Doppler and tissue Doppler imaging. In particular, we focused on early transmitral flow to early diastolic motion velocity of mitral annulus ratio (E/Ea), useful to estimate normal or elevated LVFP. However, when found in intermediate range (8–15), its role is unclear. Methods and Results: We evaluated 26 patients with ischemic and 21 patients with idiopathic DCM. To validate the echocardiographic estimation of LVFP, a sample (12 patients) underwent LVFP assessment by catheterization. In idiopathic DCM, E/Ea directly related to duration of retrograde pulmonary venous flow (ARd) (r = 0.66 P = 0001). In ischemic DCM E/Ea inversely related only to systolic to diastolic velocity ratio of pulmonary venous flow (S/D) (r =−0.56 P = 0002). After a mean follow up of 6 months, by a second echocardiogram we observed a direct relation between E/Ea and ARd percentage variation (r = 0.52 P = 0.02) in idiopathic DCM group, whereas in the ischemic DCM group there was an inverse relation between E/Ea and S/D percentage variation (r =−0.59 P = 0.02).Conclusions: In conclusion, ARd in idiopathic and S/D in ischemic DCM might be used as specific additional information to estimate LVFP when E/Ea falls within intermediate range.     

多普勒超声对左室舒张压升高的评估作用

目的探讨二尖瓣口血流频谱和瓣环的组织多普勒频谱与左室平均舒张压的关系。方法将79例患者分为正常组、早期舒张功能不全组和假性正常化组,测量其二尖瓣口的血流频谱（E、A、E/A比值和E峰减速时间DT）、二尖瓣环的组织多普勒频谱（s、e、a和e/a比值）、肺静脉血流频谱（PVs、PVd）及E/e。结果与假性正常化组的E/e比值比较,显著高于其它两组（P<0.01）;与假性正常化组的左室平均舒张压（mLVDP）为（12.6±2.8）mmHg比较,显著高于早期舒张功能不全组的左室平均舒张压（6.8±1.7）mmHg（P<0.01）,E/e比值与左室平均舒张压（mLVDP）呈较好的相关性（r=0.83,P<0.01）。结论E/e比值增高对评估mLVDP升高意义较大。     

The effect of successful electrical cardioversion on left ventricular diastolic function in patients with persistent atrial fibrillation: a tissue Doppler study

BACKGROUND: Changes in mitral inflow and pulmonary venous flow after electrical cardioversion (ECV) in patients with persistent atrial fibrillation (AF) were showed in many former studies. In our study we investigated the effects of ECV on diastolic parameters by using tissue Doppler imaging (TDI) in patients with persistent AF. METHODS: Forty-one (24 women) consecutive patients underwent successful elective ECV for nonvalvular persistent AF, and maintained sinus rhythm for 1 month were enrolled to the study. Transthoracic echocardiography was applied to all patients before, 24 hours after and 1 month after ECV. Mitral annular TDI parameters were also measured with mitral inflow, pulmonary venous flow, and other standard echocardiographic measurements. RESULTS: No differences in peak myocardial early velocity (Em), deceleration time of Em, and myocardial isovolumic relaxation time measured from mitral lateral annulus before, 24 hours after, and one month after ECV were found. Peak myocardial late velocity measured 24 hours after ECV increased significantly at the end of 1 month. CONCLUSION: There were not any changes in LV diastolic function except restoration of atrial mechanical contraction following ECV in patients with persistent AF.     

Ratio of early transmitral velocity to lateral mitral annular early diastolic velocity has the best correlation with wedge pressure following cardiac surgery.

BACKGROUND: Although previous investigators reported that mitral annular velocity predicts mean pulmonary capillary wedge pressure (PCWP), it is unknown whether the lateral or septal mitral annular velocity more faithfully predicts PCWP after cardiac surgery. METHODS AND RESULTS: To assess the effect of cardiac surgery on the predictive values for PCWP by measuring mitral annular velocity, 52 consecutive patients undergoing cardiac surgery were studied. All patients underwent transthoracic echocardiography and right-sided cardiac catheterization both before and after surgery. The peak early diastolic velocity of transmitral flow (E) was measured by pulsed-wave Doppler and the peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus by pulsed-wave tissue Doppler imaging. The ratios of E to LEa (E/LEa) and SEa (E/SEa) were calculated. Immediately after echocardiography, PCWP was measured using a balloon-tipped pulmonary artery catheter. After surgery, LEa was significantly increased (6.4+/-2.7 vs 8.6+/-3.3 cm/s, p<0.001), but SEa was unchanged (6.0+/-2.5 vs 5.5+/-2.3 cm/s, p=0.09). E/LEa correlated well with PCWP both before and after surgery (r=0.79 and r=0.69, respectively, p<0.001). Although E/SEa correlated well before surgery (r=0.67, p<0.001), it correlated only weakly after surgery (r=0.44, p<0.01). CONCLUSIONS: E/LEa has the best correlation with PCWP both before and after cardiac surgery and may be more useful than E/SEa in the noninvasive estimation of PCWP.     

Comparison of usefulness of left ventricular diastolic versus systolic function as a predictor of outcome following primary percutaneous coronary angioplasty for acute myocardial infarction

Left ventricular (LV) diastolic function is an important predictor of morbidity and mortality after acute myocardial infarction (AMI). We evaluated the role of diastolic function in predicting in-hospital events and LV ejection fraction (EF) 6 months after a first AMI that was treated with primary percutaneous coronary intervention (PCI). We prospectively enrolled 59 consecutive patients who were 60 +/- 15 years of age (48 men), presented at our institution with their first AMI, and were treated with primary PCI. Patients underwent 2-dimensional and Doppler echocardiography, including tissue Doppler imaging of 6 basal mitral annular regions within 24 hours after primary PCI and were followed until discharge. Clinical and echocardiographic variables at index AMI were compared with a combined end point of cardiac death, ventricular tachycardia, congestive heart failure, or emergency in-hospital surgical revascularization. Follow-up echocardiographic assessment was performed at 6 months in 24 patients. During hospitalization, 3 patients died, 7 developed congestive heart failure, 4 had ventricular tachycardia, and 1 required emergency surgical revascularization. Stepwise logistic regression analysis showed the ratio of early mitral inflow diastolic filling wave (E) to peak early diastolic velocity of non-infarct-related mitral annulus (p < 0.01) (E') and mitral inflow E-wave deceleration time (p < 0.02) to be independent predictors of in-hospital cardiac events (generalized R2 = 0.66). In a stepwise multiple linear regression model, independent predictors of follow-up LVEF were mitral inflow deceleration time (R2 = 0.39, p = 0.002), baseline LVEF (R2 = 0.54, p < 0.02), and mitral inflow peak early velocity/mitral annular peak early velocity (or E/E') of infarct annulus (R2 = 0.66, p = 0.02). In conclusion, in patients who are treated with primary PCI for a first AMI, E/E' velocity ratio and mitral inflow E-wave deceleration time are strong predictors of in-hospital cardiac events and of LVEF at 6-month follow-up.     

Doppler echographic evaluation of mitral valve stenosis with atrial fibrillation. Construction of a nomogram]

Doppler echocardiographic evaluation of mitral stenosis is often difficult in patients with atrial fibrillation. Sixteen patients were examined by transthoracic Doppler echocardiography and the relation between the variations in transmitral end diastolic pressure gradient and the length of the corresponding cardiac cycles was analysed. Mitral valve surface area (1.65 +/- 0.73 cm2) was determined by the pressure half-time method. The end diastolic transmitral pressure gradient was calculated from the simplified Bernouilli formula applied to end diastolic mitral flow velocity. In each patient, a linear relationship was observed between the end diastolic mitral gradient and the corresponding RR interval. The slope and intercept of the graph correlated significantly to mitral valve surface area (r = 0.72, p < 0.002 and r = 0.93, p < 0.00001, respectively). Using regression equations describing these correlations, it has been possible to construct a nomogramme indicating mitral valve surface area as a function of mitral end diastolic pressure gradient and the duration of the corresponding RR cycle. This nomogramme facilitates Doppler evaluation of mitral stenosis in atrial fibrillation.     

Left ventricular diastolic function and exercise capacity in community-dwelling adults ≥65 years of age without heart failure

Left ventricular diastolic dysfunction (LVDD) has been reported to have strong correlation with exercise capacity. However, this relationship has not been studied extensively in community-dwelling older adults. Data on pulse and tissue Doppler echocardiographic estimates of resting early (E) and atrial (A) transmitral peak inflow and early (Em) mitral annular velocities, and six-minute walk test were obtained from 89 community-dwelling older adults (mean age, 74; range, 65-93 years; 54% women), without a history of heart failure. Overall, 47% had cardiovascular morbidity and 60% had normal diastolic function (E/A 0.75-1.5 and E:Em <10). Among the 36 individuals with LVDD, 83%, 14% and 3% had grade I (E/A <0.75, regardless of E/E(m)), II (E/A 0.75-1.5 and E/E(m) ≥10) and III (E/A>1.5 and E/E(m) ≥10) LVDD, respectively. Those with LVDD were older (77 versus 73 years; p = 0.001) and had a trend for higher prevalence of cardiovascular morbidity (58% versus 40%; p = 0.083). LVDD negatively correlated with six-minute walk distance (1013 versus 1128 feet; R = -0.25; p = 0.017). This association remained significant despite adjustment for cardiovascular morbidity (R = -0.35; p = 0.048), but lost significance when adjusted for age (R = -0.32; p = 0.105), age and cardiovascular morbidity (R = -0.38; p = 0.161), and additional adjustment for sex, race, body mass index, and systolic blood pressure (R = -0.44; p = 0.365). In conclusion, most community-dwelling older adults without heart failure had normal left ventricular diastolic function or grade-I LVDD. Although LVDD was associated with decreased performance on a six-minute walk test, that association was no longer evident after adjustment for age, body mass index and cardiovascular morbidity.