Factors influencing Doppler indexes of left ventricular filling in healthy persons

Ninety-three healthy persons aged 11 to 91 years were studied to assess the factors influencing Doppler indexes of left ventricular (LV) diastolic filling. The effects of physical activity, alcohol consumption and smoking were tested in addition to those of age, sex, heart rate, body mass index, blood pressure, left atrial diameter, and LV end-diastolic diameter, wall thickness, mass and fractional shortening. The data were fitted stepwise into multiple linear regression models both in the total population and in 3 groups aged less than 40, 40 to 60 and greater than 60 years. In the total population, age explained 45 to 68% of the variation in the peak early and late diastolic velocities, their ratio, deceleration of the early velocity, atrial filling fraction and peak filling rate normalized to mitral stroke volume. With advancing age--and with increases in either body mass index, heart rate, diastolic blood pressure or LV mass--the indexes of early filling decreased, whereas with regular modest use of alcohol or regular aerobic exercise they increased (p less than 0.05 for all). In the middle-aged subjects, gender explained 32 to 57% of the variation in the peak atrial velocity, early to atrial peak velocity ratio and atrial filling fraction; the peak velocity ratio measured 1.4 +/- 0.3 (mean +/- standard deviation) in men vs 1.0 +/- 0.2 in women (p less than 0.001). In conclusion, many constitutional and physiologic factors and even life-style can influence the Doppler indexes of LV filling. This demonstrates the exquisite sensitivity of the method but indicates also that individual measurements must be interpreted with caution.     

Age-dependent influence of heart rate on Doppler indexes of left ventricular filling

Abstract. Background and objective . The Doppler indexes of left ventricular filling are related to age and heart rate. The aim of this study was to assess whether the influences of heart rate and age interactions (that is, whether the effect of heart rate on the Doppler indexes) is modified by age. Subjects and methods . The effects of atropine-induced heart rate increases on the transmitral velocities were compared in 10 younger healthy subjects aged 26–38 years and 12 older healthy subjects aged 50–67 years. Results . With a comparable total rise in heart rate (on average 20 beats min^-1), the peak early diastolic velocity decreased likewise in both groups (from 66±9 to 57±9 cm s^-1 in the younger age group and from 58 ± 15 to 47±13 cm s^-1 in the older age group). The peak atrial velocity remained unaltered in the older group (53 ± 16 vs. 52 ± 14 cm s^-1) but rose from 33 ± 6 to 44 ± 12 cm s^-1 in the younger (P = 0.02). The early-to-atrial peak velocity ratio decreased from 1.2 ± 0.6 to 1.0 ± 0.4 cm s^-1 in the older subjects and from 2.0 ± 0.5 to 1.4 ± 0.5 cm s^-1 in the younger subjects (P = 0.01). Changes in the other Doppler indexes were similar in both groups. Conclusions . The effect of heart rate on certain Doppler indexes of left ventricular filling is age-dependent. The peak velocity ratio cannot be interpreted without adjusting for heart rate in younger subjects, whilst in older people heart rate variation is of less importance.     

102名健康中年人运动试验前后舒张功能的正常变异

目的观察健康中年人运动试验前后舒张功能的变化.方法使用多普勒彩色超声心动图仪分别测量102名健康中年人静息时、运动试验后15min及60min的E峰最大流速(EPFV)、A峰最大流速(APFV)、EPFV/APFV(E/A)比值、E峰减速时间(Edt). 结果健康中年人运动试验后15min及60min EPFV、E/A比值、Edt与静息时相比均明显下降.APFV运动试验前后无差异.运动试验后15min E/A比值比静息时降低0.5以内. 结论健康中年人运动试验后舒张功能存在生理性下降,运动后15min的E/A比值较静息时明显降低,但应＜0.5.     

102名健康中年人运动试验前后舒张功能的正常变异

目的：观察健康中年人运动试验前后舒张功能的变化。方法：使用多普勒彩色超声心动图仪分别测量102名健康中年人静息时、运动试验后15min及60min的E峰最大流速（EPFV）、A峰最大流速（APFV）、EPFV／APFV（EK／A）比值、E峰减速时间（Edt)。结果：健康中年人运动试验后15min及60min EPFV、E／A比值、Edt与静息时相比均明显下降。APFV运动试验前后无差异。运动试验后15min E/A比值比静息时降低0．5以内。结论：健康中年人运动试验后舒张功能存在生理性下降，运动后15min的E／A比值较静息时明显降低，但应＜0．5。     

Doppler echocardiographic evaluation of right and left ventricular filling in hypertension]

Left (LV) and right ventricular (RV) filling was evaluated by pulsed doppler echocardiography in 56 hypertensive (HTN) untreated patients and in 30 normotensive (N) subjects, matched for age, body surface and heart rate. HTN were classified in two groups: HTN1: with normal LV mass index (LV mi) (< 135 g.m-2 for men, < or = 115 g.m.-2 for women); HTN2: with increased LV mi (> or = 135 g.m-2 for men, > or = 115 g.m-2 for women). All subjects had normal systolic function by echo. We derived: LV wall thickness (h), antero-posterior radius (r), h/r ratio, LV mi, ratio of early to late filling (E/A) in both ventricle. RESULTS. h and h/r were significantly in HTN1 (p < 0.01 vs N) and particularly in HTN2 (p < 0.001 vs N and HTA1). E/ALV and E/ARV were significantly decreased (p < 0.001) in both HTA compared to N. There was no significant difference between HTN1 and HTN2 concerning E/ALV and E/ARV. Relations of E/ALV and E/ARV with age, systolic blood pressure (SBP), LV mi, h, h/r: [table: see text] E/ALV is correlated to E/ARV (r = 0.37; p < 0.01) only in HTA. CONCLUSIONS. 1) In HTN in comparison with N: h, h/r are higher in the presence but also in the absence of increased LV mi. 2) In N and HTN: E/ALV and E/ARV are better correlated to h (and also to h/r in N) than to LV mi. Though the respective values of E/ALV and E/ARV are identical, they are correlated significantly only in HTN. 3) In the absence of the direct measures of the RV pressures and volumes, the interpretation of the results concerning the RV filling in uncertain. Only in HTN, they could be explained at least in part by the diastolic interplay between the two ventricles.     

Diastolic blood pressure as a determinant of Doppler left ventricular filling indexes in normotensive adolescents

Alterations in left ventricular filling can occur with aging and in patients with hypertension, ischemic heart disease, congestive and hypertrophic cardiomyopathy and congenital heart disease. This study examines the effects of blood pressure on left ventricular diastolic filling indexes measured by Doppler ultrasound technique in 47 young normotensive adolescents (mean age 13 years). Left ventricular filling was assessed by Doppler peak early and late diastolic transmitral flow velocities, early and late diastolic flow velocity integrals and early diastolic deceleration. Systolic blood pressure did not correlate with any of the Doppler filling indexes, although it was related to echocardiographic left ventricular mass (r = 0.44, p less than 0.005). Diastolic blood pressure did not correlate with left ventricular mass; however, it was inversely related to peak early diastolic flow velocity (r = -0.44, p less than 0.005), early diastolic flow velocity integral (r = -0.40, p less than 0.01) and early diastolic deceleration (r = -0.32, p less than 0.05). The ratio of late to early peak filling (A/E) was directly related to diastolic blood pressure (r = 0.48, p less than 0.001). Examination of electrocardiograms showed that there was a stronger correlation between A/E ratio and diastolic blood pressure (r = 0.63) in 22 subjects with bimodal P waves in lead V1 than in subjects with unimodal P waves (r = 0.45).(ABSTRACT TRUNCATED AT 250 WORDS)     

Age-related alterations of Doppler left ventricular filling indexes in normal subjects are independent of left ventricular mass, heart rate, contractility and loading conditions

The purpose of this study was to determine whether age-related alterations in Doppler diastolic filling indexes occur independent of cardiovascular disease and confounding physiologic variables. Ten old (62 to 73 years) and 10 young (21 to 32 years) healthy male volunteers were rigorously screened for cardiovascular disease and underwent comprehensive Doppler echocardiography, radionuclide ventriculography and invasive measurements of right heart and left atrial pressures. There were no differences between the two groups in the physiologic variables of left ventricular mass, volumes, ejection fraction, end-systolic wall stress, left atrial size, heart rate and right atrial, pulmonary artery, pulmonary capillary wedge and systemic arterial pressures. However, there were marked differences in Doppler left ventricular filling indexes. Compared with the young group, the old group had reduced peak early diastolic flow velocity (56 +/- 13 vs. 82 +/- 12 cm/s, p = 0.0002) and increased atrial diastolic flow velocity (59 +/- 14 vs. 43 +/- 10 cm/s, p = 0.009) and had a peak atrial/early flow velocity (A/E) ratio twice that of the young group (1.09 +/- 0.29 vs. 0.54 +/- 0.15, p less than 0.0001). Similar results were obtained for the time-velocity integrals of the peaks. Subjects in the old group also had a markedly reduced peak filling rate (274 +/- 62 vs. 448 +/- 152 ml/s, p = 0.004). In univariate and multivariate regression analyses, peak early and atrial flow velocities were not related to any of the physiologic variables measured once age was accounted for, although peak filling rate, a volumetric measure flow, was related to body surface area as well as age.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler assessment of right ventricular filling in a normal population. Comparison with left ventricular filling dynamics

To examine whether alterations in right ventricular filling dynamics occur with increasing age and to compare right and left ventricular filling in normal subjects, pulsed Doppler echocardiographic studies were performed at the tricuspid and mitral anuli in 50 normal volunteers (23 males and 27 females) with an age range of 5-66 years. An age-related decrease in peak early filling velocity, increase in peak late velocity, and augmentation in the late/early ratio of peak velocities at the tricuspid anulus were observed (r = -0.68, 0.63, and 0.84, respectively). Significant correlations were also found between age and first third, first half, and atrial filling fractions (r = -0.60, -0.72, and 0.69, respectively). Weaker relations were observed between heart rate and Doppler-derived diastolic parameters (r = 0.18-0.54). Right ventricular filling indexes related significantly to those of the left ventricle (r = 0.58-0.88), the best being for the late/early ratio of peak velocities. With inspiration, an increase in early and late right ventricular filling occurred, whereas a reduction in filling occurred in the left ventricle. Thus, careful consideration for age, heart rate, and respiration is necessary in examining the effect of disease states or therapeutics on the filling dynamics of either the right or left ventricle.     

Doppler assessment of right ventricular filling dynamics in systemic hypertension: comparison with left ventricular filling.

To assess right ventricular filling dynamics in systemic hypertension, pulsed Doppler echocardiographic studies were obtained at the tricuspid and mitral anuli in 43 untreated hypertensive patients, aged 23 to 66 years, and in 42 age-matched normotensive control subjects. In hypertensive patients, the ratio of late to early peak filling velocity and atrial filling fraction were higher, while normalized peak filling rate, one third and one half filling fractions were lower, compared with control values. Right ventricular filling dynamics correlated poorly with age in hypertensive patients, and were unrelated to left ventricular mass or left ventricular wall thickness. Weak correlations were only found between right ventricular wall thickness and right ventricular peak late inflow velocity, first half and first third filling fractions. However, right ventricular filling dynamics were closely related to left ventricular filling dynamics in both hypertensive patients (r = 0.49 to 0.82) and normal individuals (r = 0.55 to 0.86). Thus right ventricular filling dynamics are altered in hypertension, independently of left ventricular mass or blood pressure, are weakly related to right ventricular thickness, but remain closely correlated to left ventricular filling dynamics.     

Doppler assessment of left ventricular diastolic filling during brief coronary occlusion

To assess left ventricular diastolic filling in patients with single-vessel coronary artery disease, Doppler-derived transmitral velocity was studied in 22 normal subjects and in 15 patients with isolated proximal stenosis of the left anterior descending coronary artery (LAD) and normal systolic function of the left ventricle. Transmitral velocity was recorded before and after balloon inflation during coronary angioplasty. At baseline the transmitral velocity pattern in patients with LAD stenosis differed from that of normal subjects with a significant (p at least less than 0.05) decrease in the early diastolic filling phase (E area 0.094 +/- 0.022 m in normal subjects vs 0.078 +/- 0.008 m in patients) and an increase in the late diastolic filling phase (A area 0.034 +/- 0.007 m vs 0.042 +/- 0.008 m). Correspondingly the ratio E area/A area decreased (2.7 +/- 0.51 vs 1.9 +/- 0.4) and the ratio A area/total area increased (0.28 +/- 0.04 vs 0.35 +/- 0.05). During coronary occlusion the E area and the ratio E area/A area decreased further, whereas the A area and the ratio A area/total area increased. The results suggest that patients with single-vessel disease and normal systolic function often exhibit an altered pattern of transmitral velocity even in the absence of overt ischemia, and that during acute regional ischemia early diastolic filling is further compromised with compensatory enhancement of the late diastolic filling phase.     

European reference values for Doppler indices of left ventricular diastolic filling

The European Study Group on diastolic heart failure requires objective evidence of abnormal left ventricular diastolic function to establish the diagnosis of diastolic heart failure, which is common in older people. Reference values for Doppler indices of transmitral flow, used to assess left ventricular diastolic function, have not been reported for people 70 years and over in Europe. The aim of this study was to establish reference values for these Doppler indices of transmitral flow in older people. A random sample of 355 subjects aged 70 and over, living in the community underwent clinical assessment and echocardiography. Asymptomatic subjects with no cardiovascular disease and cardiovascular risk factors were identified. Measurements of five commonly used Doppler indices of transmitral flow from these subjects were obtained and reference range expressed as mean+/-2 standard deviations and as percentiles. We have therefore generated reference Doppler values of transmitral flow for people aged over 70 in a British population.     

Pulsed Doppler echocardiographic study of left ventricular filling in dilated cardiomyopathy

Patients with dilated cardiomyopathy (DC) have been reported to have abnormal left ventricular (LV) diastolic properties. To evaluate LV diastolic filling characteristics in patients with DC, pulsed Doppler echocardiography was used to study mitral flow velocity in 21 patients with DC and mitral regurgitation (MR), 12 patients with DC but no MR and 19 age-matched normal subjects. Diagnosis of MR was based on the Doppler echocardiographic finding of holosystolic turbulent flow in the left atrium. Peak mitral flow velocity in early diastole (PFVE) and during atrial systole (PFVA), PFVA/PFVE and deceleration half-time of early diastolic flow were measured from Doppler mitral flow velocity recordings. In 21 patients with DC and MR, PFVE (61 +/- 13 cm/s), PFVA (37 +/- 19 cm/s) and PFVA/PFVE (0.6 +/- 0.4) were not significantly different from PFVE (53 +/- 10 cm/s), PFVA (47 +/- 12 cm/s) and PFVA/PFVE (1.0 +/- 0.4) in normal subjects (p greater than 0.05). Deceleration half-time in DC patients with MR (62 +/- 32 ms) was shorter than normal (87 +/- 25 ms) (p less than 0.05). In contrast, PFVE (31 +/- 11 cm/s) was lower and PFVA/PFVE (1.7 +/- 0.8) was higher in the 12 DC patients without MR than in normal subjects and DC patients with MR (p less than 0.005). PFVA (46 +/- 8 cm/s) and deceleration half-time (88 +/- 33 ms) in patients without MR were not significantly different from normal mean values. Thus, abnormalities of peak diastolic mitral flow velocity were detected in DC patients without MR but not in DC patients with MR, suggesting that MR masks LV filling abnormalities in patients with DC.     

Doppler echocardiographic analysis of left ventricular filling in treated hypertensive patients

Early detection and prevention of cardiac dysfunction is an important goal in the management of hypertensive patients. In this study, Doppler echocardiography was used to evaluate the pattern of left ventricular diastolic filling in 38 subjects: 18 treated hypertensive patients (blood pressure 141 +/- 17/83 +/- 10 mm Hg, mean +/- SD) without other coronary risk factors and 20 risk-free normotensive subjects of similar age (47 +/- 10 and 49 +/- 13 years, respectively). Peak velocity of late left ventricular filling due to the atrial contraction was greater in hypertensive compared with normotensive subjects (69 +/- 14 versus 52 +/- 13 cm/s; p less than 0.001). Peak velocity of late filling was significantly greater in hypertensive versus normotensive subjects in those aged 50 years or younger and those older than age 50 (65 +/- 12 versus 50 +/- 11; p less than 0.01 and 75 +/- 15 versus 56 +/- 15 cm/s; p less than 0.05, respectively). In hypertensive subjects, peak velocity of late filling did not correlate with routine indexes of hypertensive heart disease (including posterior wall thickness and left ventricular mass), systolic and diastolic blood pressure or duration of hypertension. These results indicate that increased velocity of late left ventricular filling may be independent of left ventricular hypertrophy and persist despite effective blood pressure control.     

Relationship between angiographic infarct size and left ventricular filling.

Infarct size may influence left ventricular filling after acute myocardial infarction. Pulsed Doppler transmitral flow velocities were compared in 47 patients at 7 +/- 6 days following acute myocardial infarction and 47 age-matched controls. Patients were stratified by angiographic infarct size into Groups I, II, III (corresponding angiographic hypokinetic scores less than 2; 2-2.99; greater than or equal to 3 SD/cord). Early diastolic transmitral Doppler flow velocities did not differ between infarct groups but atrial transmitral Doppler flow measurements did: peak A velocity (p = 0.001), A velocity time integral (p less than 0.001), and total velocity time integral (p = 0.001). Compared to controls atrial transmitral Doppler flow was augmented in Group I, whilst atrial and total transmitral Doppler flow were depressed in Group III. Peak A velocity and A velocity time integral were inversely related to infarct size (R = -0.44 to -0.54) and directly to left ventricular ejection fraction (R = 0.59 to 0.65). Large infarct size following myocardial infarction is associated with lower atrial and total transmitral Doppler flow velocities.     

Study of left ventricular blood filling during post-pacing ischemia: comparison of Doppler echocardiography and heart catheterization]

Left ventricular blood filling was performed in 72 patients by using pulsed Doppler echocardiography at rest and in postpacing ischemia. In 10 patients, non-invasive examination findings were compared with the values of a left ventricular pressure curve which had been obtained in frequent atrial pacing. No changes in transmitral blood flow were found in patients without coronary heart disease, whereas 2 types of abnormal transmitral blood flow were detected in those with coronary heart disease in the postpacing period. The patients with Type I abnormal transmitral blood flow exhibited prolonged isovolumetric relaxation and slightly elevated left ventricular end-diastolic pressure in the postpacing period when catheterization was conducted. Those with Type I ("pseudonormal") transmitral blood flow displayed more prolonged relaxation and significantly (greater than 20 mm Hg) elevated end-diastolic pressure. The pattern of changes in transmitral blood flow was not pathognomonic to any definite myocardial abnormality, but reflected the hemodynamics.     

Association of left ventricular filling parameters assessed by pulsed wave Doppler and color M-mode Doppler echocardiography with left ventricular pathology, pulmonary congestion, and left ventricular end-diastolic pressure

Among 90 consecutive patients with various degrees of left ventricular (LV) dysfunction (normal patients, LV hypertrophy, LV ejection fraction <50%, and <30%), the mitral valve pulse-wave E/A ratio showed a characteristic U-shaped curve with increasing severity of LV dysfunction. In contrast, there was a significant progressive decrease in flow propagation velocity of the E-wave (Vp) and a significant increase in E/Vp values with increasing severity of LV dysfunction. The E/Vp ratio was the best predictor of pulmonary congestion, and in a subgroup of patients who underwent cardiac catheterization, it was the only significant predictor of LV end-diastolic pressure.     

Alterations in transesophageal pulsed Doppler indexes of filling of the left ventricle after pericardiotomy

The impact of pericardial constraint on patterns of left ventricular filling was measured by transesophageal pulsed Doppler echocardiography in 30 patients undergoing elective nonvalvular cardiac surgery. Peak early left ventricular filling velocity increased from 0.52 +/- 0.11 to 0.56 +/- 0.15 m/s (p less than 0.05) and early left ventricular filling fraction increased from 60 +/- 9% to 65 +/- 9% (p less than 0.005) after pericardiotomy. The study group was retrospectively subdivided into two groups based on the prepericardiotomy mean right atrial pressure, an index of intrapericardial pressure and hence pericardial constraint. In 13 patients with a mean right atrial pressure less than 6 mm Hg, no significant changes in early left ventricular filling were evident after pericardiotomy. In 17 patients with a mean right atrial pressure greater than or equal to 6 mm Hg indicative of a greater degree of pericardial constraint before pericardiotomy, significant increases in peak early filling velocity (0.52 +/- 0.13 to 0.57 +/- 0.19 m/s, p less than 0.05), peak early filling rate (4.29 +/- 0.67 to 4.66 +/- 0.86 stroke volumes/s, p less than 0.05) and early left ventricular filling fraction (57 +/- 7% to 63 +/- 8%, p less than 0.001) were measured after pericardiotomy. Thus, the pericardium does constrain early left ventricular filling and its effects are more pronounced in patients with an elevated right atrial pressure.