Comparison of myocardial tissue Doppler with transmitral flow Doppler in left ventricular hypertrophy

We sought to determine the most useful echocardiographic measurements for assessment of diastolic function in patients with left ventricular hypertrophy (LVH) and normal systolic function. We compared myocardial Doppler velocities of the basal inferoposterior wall with mitral inflow pulsed wave Doppler velocities in 11 healthy volunteers (age, 36 +/- 6 years), 25 patients (age, 64 +/- 14 years) without LVH, and 37 patients (age, 67 +/- 14 years) with LVH and otherwise normal echocardiograms. The discriminatory measurements were myocardial A-wave duration (120 +/- 18 versus 98 +/- 20 and 92 +/- 12 ms, P <.0001), myocardial isovolumetric relaxation time (124 +/- 45 versus 95 +/- 48 and 78 +/- 25 ms, P =.0035), mitral A-wave velocity (0.98 +/- 0.37 versus 0.73 +/- 0.28 m/s and 0.61 +/- 0.22 m/s, P =.009), and mitral E-wave deceleration time (257 +/- 93 versus 201 +/- 85 ms and 184 +/- 83 ms, P =.015), which were significantly increased, and myocardial E-wave velocity (0.84 +/- 0.04 m/s versus 0.13 +/- 0.03 m/s and 0.14 +/- 0.03 m/s, P <.0001), which was significantly decreased, in patients with LVH compared with patients without LVH and normal volunteers, respectively. Left ventricular posterior wall thickness correlated with myocardial isovolumetric relaxation time (r = 0.52, P <.0001) and myocardial A-wave duration (r = 0.59, P <.0001), negatively with myocardial E wave (r = -0.43, P <.0001), and showed no correlation with mitral inflow parameters except mitral inflow A wave (r = 0.43, P =.002). On multivariate analysis using these variables, myocardial isovolumetric relaxation time (P =.0014) and A-wave duration (P =.001) were the only 2 variables that correlated with posterior wall thickness (multiple R = 0.71). In the presence of LVH and preserved left ventricular systolic function, myocardial relaxation time and velocities are more sensitive than mitral Doppler inflow parameters in detecting abnormal left ventricular relaxation.     

Mitral regurgitation and left ventricular diastolic dysfunction similarly affect mitral and pulmonary vein flow Doppler parameters: the advantage of end-diastolic markers.

Enhanced early mitral flow and reduced systolic pulmonary vein flow may be caused both by increased left ventricular pressure as the result of diastolic dysfunction and by increased transmitral flow as the result of mitral regurgitation. Nevertheless, Doppler parameters are widely used to predict left ventricular filling pressure. We aimed to analyze the interference of mitral regurgitation with Doppler parameters usually used to estimate left ventricular filling pressure and to identify markers independent of mitral regurgitation, which could reliably estimate increased left ventricular filling pressure. Eighty-four patients (age, 62 +/- 9 years; 82% men) had a complete echocardiographic Doppler examination. Transmitral E- and A-wave velocity, E deceleration time and A duration, pulmonary vein systolic and diastolic velocities, and reversal flow duration and maximal and minimal left atrial volumes were measured. The difference between the duration of pulmonary vein and mitral A waves was calculated (A'-A). Mitral regurgitant volume was quantitatively assessed by echocardiography. Left ventricular end-diastolic pressure was measured invasively. Patients had a wide range of left ventricular ejection fraction (14% to 70%), mitral regurgitant volume (0 to 94 mL), and left ventricular end-diastolic pressure (3 to 37 mm Hg). E velocity, E/A, pulmonary vein systolic and diastolic, and systo-diastolic ratios were significantly and independently correlated with both left ventricular end-diastolic pressure and mitral regurgitant volume. A'-A showed a strong correlation with left ventricular end-diastolic pressure (r = 0.70; P <.0001), but the relation with mitral regurgitant volume was not significant (r = 0.19; P =.08). Mitral regurgitation affects the majority of Doppler parameters widely used to predict filling pressure but does not influence Ad'-Ad, which proved to be the strongest predictor of left ventricular end-diastolic pressure.     

肥厚型心肌病患者左室内血流空间分布的探讨

目的探讨肥厚型心肌病(HCM)患者左室内血流空间分布情况.方法应用脉冲波多普勒测定17例HCM患者二尖瓣瓣尖、瓣下1、2、3、4 cm处的血流频谱,测量指标包括舒张早期E波流速峰值(E0、E1、E2、E3、E4,cm/s)和舒张晚期A波流速峰值(A0、A1、A2、A3、A4,cm/s),计算E/A比值(E/A0、E/A1、E/A2、E/A3、E/A4),并与13例正常人对照.结果正常人左室腔内血流速度呈均匀一致的变化,即从二尖瓣瓣尖至距瓣尖4 cm处,E波和A波流速逐渐减低,尽管E波流速呈减低趋势,但E0与E4相比,差异无显著性意义(P＞0.05),而A0和A1明显高于A2、A3、A4(P＜0.05);在HCM患者中,A波流速逐渐减低,A1明显高于A3、A4(P＜0.05),但E波流速呈先减低后升高再减低的趋势,在距二尖瓣瓣尖3 cm处明显加速(P＜0.05).E波流速在左室腔内的空间分布呈两种形式:在大多数患者(12例)中表现为左室腔内距二尖瓣瓣尖3 cm处流速加快(E3/E0＞1),在部分患者(5例)中表现为流速减慢(E3/E0＜1).结论肥厚型心肌病患者左室腔内舒张早期E波流速呈先减低后升高再减低的趋势,在距二尖瓣瓣尖3 cm处明显加速,A波流速呈减低趋势.     

Color M-mode and Doppler tissue evaluation of diastolic function in children: simultaneous correlation with invasive indices.

OBJECTIVE: The purpose of this study was to explore the validity of diastolic indices derived from color M-mode Doppler and Doppler tissue imaging in a heterogeneous group of pediatric patients by comparing them with simultaneously obtained invasive indices of diastolic function. METHODS: A total of 20 children undergoing left heart catheterization had echocardiographic images recorded simultaneously with high-fidelity left ventricular (LV) pressure tracings. Transmitral Doppler, pulmonary vein Doppler, Doppler tissue imaging, and color M-mode Doppler flow propagation velocity were recorded. LV peak negative dP/dt, the time constant of isovolumic relaxation, and LV end-diastolic pressure were compared with the echocardiographic indices. RESULTS: The ratio of peak E-wave mitral velocity/propagation velocity correlated significantly with LV end-diastolic pressure (r = 0.71; P <.001). Propagation velocity correlated with the time constant of isovolumic relaxation (r = -0.56; P =.01) and peak negative dP/dt (r = 0.50; P <.03). Septal mitral annular myocardial velocity correlated significantly with the time constant of isovolumic relaxation (r = -0.58, P =.01). CONCLUSION: The newer diastolic indices derived from color M-mode Doppler and Doppler tissue imaging appear to be a helpful adjunct in the noninvasive assessment of diastolic function in children.     

舒张早期心内充盈减射评价左室舒张功能研究

目的：探讨应用超声心动图测量心室内舒张早期心内充盈减射评价左室舒张功能。方法：连续观察92例受检者,其中正常者19例,高血压患者26例,冠心病47例（其中A／E＞132例）;A／E＜110例;房颤5例）,将脉冲多普勒取样容积置于二尖瓣口及离瓣口1cm、2cm、3cm分别记录心内舒张早期二尖瓣口及离瓣口1cm、2cm、3cm舒张期血流速度,测量En(n=1,2,3)峰值速度计算En与E0比值及二尖瓣口舒张期血流频谱Ao/E0比值。结果：左室舒张早期血流速度在高血压和冠心病组从二尖瓣口至心尖逐渐减低,高血压和冠心病（A／E＞1,A／E＜1,Af）组舒张期心内充盈减射E3及E3／E0比值与E0及E1／E0比值存在差异（P＜0．05）。同时E3／E0舒张功能参数与传统二尖瓣口A0／E0比值存在线性相关（r＝－0．83,P＜0．001）。结论：因此上述超声心动图指标方法可用于评价左室舒张功能,心内充盈减射E3／E0可用于传统指标评价左室舒张功能受限制A／E＜1“假正常”及房颤患者。     

An integrated measure of left ventricular diastolic function based on relative rates of mitral E and A wave propagation.

BACKGROUND AND OBJECTIVES: The mitral E wave propagation inside the left ventricle is slowed in patients with abnormal left ventricular (LV) relaxation with a prolongation of its transit time to the LV outflow tract (T(e)). On the contrary, the mitral A wave propagation is faster in those with elevated LV end-diastolic stiffness, resulting in a shortening of its transit time (T(a)). We hypothesized that the T(e)/T(a) ratio may serve an integrated measure of global LV diastolic function. METHODS AND RESULTS: The T(e)/T(a) ratio was measured with Doppler echocardiography in 94 subjects: 25 normal subjects, 38 patients with LV hypertrophy (18 with secondary LV hypertrophy and 20 with hypertrophic cardiomyopathy), and 31 patients undergoing left heart catheterization for clinical indications. The T(e)/T(a) ratio was 1. 98 +/- 0.61 in the normal subjects, 3.32 +/- 0.93 in patients with secondary LV hypertrophy (P <.0001 vs normal), and 3.18 +/- 1.36 in patients with hypertrophic cardiomyopathy (P =.0003 vs normal). In the invasive group the T(e)/T(a) ratio (range 0.56 to 3.60) correlated significantly with Tau (r = 0.76, P <.0001), peak negative dP/dt (r = -0.46, P =.01), the LV late diastolic stiffness index (r = 0.57, P =.0013), LV pre-A wave pressure (r = 0.46, P =. 0096), LV end-diastolic pressure (r = 0.58, P =.0007), and the amount of LV pressure rise with atrial systole (r = 0.52, P =.0032) but not with the heart rate. Tau and LV stiffness were its sole determinants by stepwise multiple regression (R = 0.82). CONCLUSIONS: The ratio of mitral E and A wave transit times inside the LV (T(e)/T(a) ratio) is closely related to LV relaxation, its late diastolic stiffness, and filling pressures and gives valuable insights into LV diastolic performance.     

Association of newer diastolic function parameters with age in healthy subjects: a population-based study.

OBJECTIVES: We sought to determine if newer Doppler diastolic function parameters are associated with age and to define age-stratified reference ranges for these parameters in a population-based setting. BACKGROUND: Although newer Doppler parameters aid in the evaluation of diastolic function and filling pressures, age-specific reference ranges are poorly described. METHODS: Randomly selected residents of Olmsted County, Minn, age >/= 45 years were studied (n = 2042) prospectively. Those without a history of cardiovascular disease or abnormal 2-dimensional echocardiograms were selected. Measured parameters included the transmitral early (E) and late (A) filling velocities at rest and with Valsalva, A duration, pulmonary venous atrial reversal duration, lateral and septal early diastolic mitral annular velocities, E/lateral early diastolic mitral annular velocity, E/septal early diastolic mitral annular velocity, and the index of left ventricular myocardial performance. RESULTS: A total of 1012 subjects met the inclusion criteria. Both A duration (r = 0.18, P <.001) and pulmonary venous atrial reversal duration (r = 0.28, P <.001) were longer in older subjects, whereas their difference showed a marginal correlation with age (r = 0.07, P =.036). The E/A ratio at peak Valsalva correlated with age (r = -0.54, P <.001) whereas the change in E/A with Valsalva (corrected for E-A fusion) showed a marginal correlation with age (r = 0.08, P =.032). Both E/lateral early diastolic mitral annular velocity (r = 0.39, P <.001) and E/septal early diastolic mitral annular velocity (r = 0.27, P <.001) increased with age. Left ventricular myocardial performance showed a marginal correlation with age (r = 0.08, P =.014). Age specific reference ranges (median, 5th and 95th percentiles) for all parameters are provided. CONCLUSIONS: All newer Doppler diastolic function parameters showed a variable but significant correlation with age. Age-specific reference values will aid in the interpretation of diastolic function parameters.     

高血压左室舒张早期血流传播特点及与内分泌因子的关系

目的应用超声技术探讨高血压病患者左室舒张早期血流传播特点及其与内分泌因子的关系.方法 61例高血压病患者根据左室质量指数(LVMI)分为左室心肌肥厚组(LVH,30例)和无心肌肥厚组(NLVH组,31例);20例健康者为对照组.二维及M-型超声心动图测量舒张末期室间隔厚度、左室后壁厚度、左室内径以及左室射血分数,计算LVMI.脉冲波多普勒超声测量二尖瓣血流频谱,测量舒张早期最大血流速度(E0)、舒张晚期最大血流速度(A)及其比值(E0/A),舒张早期二尖瓣瓣下3 cm处的最大血流速度(E3);舒张早期二尖瓣瓣尖心电图R波顶峰至E波峰值的时间(R-E0)、瓣下3 cm的心电图R波顶峰至E波峰值的时间(R-E3)以及两时间间期的比值(R-E3/R-E0).放射免疫分析血浆心钠素(ANP)、脑钠素(BNP)、内皮素(ET)、降钙素基因相关肽(CGRP)及血清胰岛素样类生长因子-1(IGF-1)的浓度.结果对照组、NLVH组、LVH组E0/A比值依次减小(P＜0.001);对照组、NLVH 组、LVH组E3依次降低(P＜0.05),R-E3/R-E0比值延长(P＜0.01).E0/A与ET、ANP、BNP及IGF-1呈显著负相关(r分别为-0.82,-0.65,-0.60,-0.65; P＜0.01),与CGRP中度正相关(r＝0.64,P＜0.01);E3与ET、ANP呈轻度负相关(r＝-0.36,-0.31;P＜0.01),与CGRP轻度正相关(r＝0.22,P＜0.01);R-E3/R-E0与ET、ANP、BNP及IGF-1呈显著正相关(r分别为0.61,0.62,0.79,0.73;P＜0.01),与CGRP中度负相关(r＝-0.70,P＜0.01).结论高血压病患者左室舒张早期血流传播延缓,速度减低,左室舒张功能异常与内分泌因子有关.     

Estimation of Left Ventricular End-Diastolic Pressure with the Difference in Pulmonary Venous and Mitral A Durations Is Limited When Mitral E and A Waves Are Overlapped

Previous studies showed that difference in pulmonary venous and mitral A-wave durations can be used for the estimation of left ventricular end-diastolic pressure, which is based on the assumption that the pulmonary venous A wave and mitral A wave start with the beginning of left atrial contraction. It is also assumed that the mitral A wave ends with the end of left atrial contraction. These assumptions may not be correct if left atrial contraction occurs before the early left ventricular filling is completed. Adequate Doppler mitral inflow and pulmonary venous flow signals were obtained simultaneously with left ventricular pressures at the cardiac catheterization laboratory in 50 patients who showed separated E and A waves in mitral inflow. After heart rate was increased by right atrial pacing to make the mitral E and A waves overlap, Doppler and hemodynamic measurements were repeated. When E and A waves are separated, pulmonary A-wave duration exceeding mitral A-wave duration has a sensitivity of 67% and specificity of 85% in the prediction of elevated left ventricular end-diastolic pressure (≥20 mm Hg), whereas the pulmonary A wave ending later than mitral A wave has a sensitivity of 83% and a specificity of 45%. When the mitral E and A waves are overlapped, the pulmonary A wave ending later than mitral A wave is better for the prediction of elevated left ventricular end-diastolic pressure (sensitivity 55%, specificity 75%) than pulmonary A-wave duration exceeding mitral A-wave duration (sensitivity 9%, specificity 96%). However, overall, both methods are limited for clinical use. (J Am Soc Echocardiogr 1999;12:106-12.)     

Assessment of left ventricular systolic and diastolic function by Doppler tissue imaging in patients with preinfarction angina.

BACKGROUND: The aim of this study was assessment of left ventricular (LV) systolic and diastolic function by pulsed wave Doppler tissue imaging (DTI) in patients with or without preinfarction angina in acute myocardial infarction. METHODS: We prospectively evaluated 31 consecutive patients (4 women, 27 men; age 58 +/- 10 years) with a first acute myocardial infarction. LV systolic and diastolic function was assessed by classic methods and DTI on the third day during acute myocardial infarction. Patients were divided into 2 groups according to the presence (group 1; n = 10) or absence (group 2; n = 21) of preinfarction angina. Mitral inflow velocities and early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), peak systolic mitral annular velocity, Em/Am, the ratio of early diastolic mitral inflow velocity (E) to Em, and myocardial performance index were calculated by DTI. RESULTS: Group 1 had significantly higher Em and Em/Am than group 2 (11.3 +/- 3.34 cm/s vs 7.4 +/- 2.07 cm/s, P <.0001; 1.01 +/- 0.38 cm/s vs 0.6 +/- 0.2 cm/s, P =.001, respectively). The E/Em ratio and myocardial performance index were significantly lower in group 1 than in group 2 (5.1 +/- 2.92 vs 8.10 +/- 3.15, P=.018; 0.49 +/- 0.15 vs 0.65 +/- 0.24, P =.042, respectively). Wall-motion score index was lower in those with preinfarction angina than in those without (1.6 +/- 0.36 vs 1.9 +/- 0.39; P =.04, respectively). Peak systolic mitral annular velocity and Am were not statistically different between groups (9.4 +/- 1.84 vs 8.3 +/- 2.03, P =.172; 11.7 +/- 3.07 vs 12.1 +/- 3.34, P =.72, respectively). There were no significant differences between the 2 groups regarding transmitral E velocity, atrial contraction mitral inflow velocity (A), E/A ratio, isovolumetric relaxation time, and deceleration time of the mitral E wave (P =.91, P =.08, P =.58, P =.81, and P =.71, respectively). CONCLUSION: LV diastolic function was better in patients with preinfarction angina than in patients without. This condition could not be detected by conventional mitral inflow Doppler velocities, but could be detected by DTI. This preliminary evidence shows that DTI is better than conventional mitral Doppler indices in the assessment of a favorable LV diastolic function in patients with preinfarction angina.     

Left ventricular diastolic filling prior to cardiac resynchronization therapy: implications for atrioventricular delay programming

Background: The programmed atrioventricular delay (AVD) is an important determinant of the response in left ventricular (LV) systolic performance during cardiac resynchronization therapy (CRT). It is not well established if the optimal AVD for CRT may be influenced by the LV diastolic filling pattern.
Methods: Thirty patients were studied pre- and post-CRT at programmed AVD of 60–160 ms. Doppler measurements included the aortic and mitral velocity time integral (VTI), mitral early (E) and late diastolic filling (A) wave velocities, E- and A-wave VTI, and diastolic filling time (DFT). The optimal AVD for each of the Doppler variables was defined by the maximal improvement compared to pre-CRT. Patients were grouped by the pre-CRT mitral inflow pattern as impaired relaxation (IR, mitral E/A ≤1, n = 15) or pseudonormalized/restrictive filling (PNF/RF, mitral E/A >1, n = 15).
Results: The percentage of improvement in aortic VTI was greater in the PNF/RF group (P = 0.03). Mitral E-wave velocity decreased in the PNF/RF group (P < 0 .001), E-wave VTI increased in both groups (P < 0 .05) and A-wave VTI increased in the PNF/RF group. DFT increased in both groups. The optimal AVD that maximized aortic VTI was longer than the AVD that improved DFT.
Conclusions: The effects of various programmed AVD during CRT on the response in LV stroke volume and diastolic filling are influenced by the pre-CRT LV filling characteristics. AVD optimization based on maximizing DFT is shorter compared to the aortic VTI method.     

多普勒超声对高血压患者右室舒张功能的临床研究

目的采用多普勒超声心动图检测三尖瓣口血流有关参数,研究原发性高血压(EH)患者的右室舒张功能及其相关因素.方法43例EH患者,32例正常人,取心尖四腔观,将脉冲多普勒(PWD)取样容积置于三尖瓣口,记录其血流频谱,测量舒张早期E峰流速(E)、舒张晚期A峰流速(E)和E/A比值,舒张早期E波流速积分(EVTI),舒张晚期A波流速积分(AVTI)及EVTI/AVTI比值.结果1.与对照组比较,EH组E波和EVTI下降(P＜0.05),A波和AVTI增加(P＜0.01),E/A与EVTI/AVTI比值降低(P＜0.01);2.EH患者三尖瓣E/A比值(r=0.417,P=0.005)、EVTI/AVTI比值(r=0.557,P=0.0001)与二尖瓣相应指标显著相关;3.EH患者各级血压间这些指标比较无差异(P＞0.05).结论EH患者的右室舒张功能明显下降,与左室舒张功能密切相关,与高血压分级无明显关系.     

Left ventricular end-diastolic pressure can be estimated by either changes in transmitral inflow pattern during valsalva maneuver or analysis of pulmonary venous flow.

We directly compared the transmitral inflow pattern during preload reduction and pulmonary venous flow velocities to determine left ventricular end-diastolic pressure (LVEDP) in 78 patients who underwent left heart catheterization. Transmitral inflow indexes (A-wave duration, ratio of peak flow velocity of early diastole [E] to peak flow velocity of late diastole during atrial contraction [A] [E/A ratio]) at rest and during the Valsalva maneuver (30 mm Hg for 15 seconds) and indexes of pulmonary venous flow (velocity and duration of the atrial reversal) were obtained. Fair correlations existed between LVEDP (mean 15+/-6 mm Hg) and the percentage decrease in the E/A ratio (r = 0.72), increase in duration of A wave during the Valsalva maneuver (r = 0.60), flow velocity of atrial reversal (r = 0.58), and difference of duration of atrial flow reversal and A wave (r = 0.62) (all P<.001). While sensitivity, specificity, and diagnostic accuracy to detect an elevated LVEDP were comparable, technically adequate Doppler recordings were obtained more often for the mitral inflow during the Valsalva maneuver than for the pulmonary venous flow (72 versus 66 patients, P< 0.05).     

Evaluation of left ventricular filling pressure by transthoracic Doppler echocardiography in the intensive care unit

OBJECTIVE: To determine whether Doppler transmitral and pulmonary venous flow pattern is related to left ventricular filling pressures in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Fifty-four mechanically ventilated patients (age, 63 +/- 16 yrs) were investigated via transthoracic echocardiography and Doppler. Main diagnoses were pneumonia (31%), acute exacerbation of chronic obstructive pulmonary disease (24%), congestive heart failure (11%), and poisoning (11%). INTERVENTIONS: Doppler examinations were performed simultaneously with measurements of pulmonary artery occlusion pressure via a right heart catheter. MEASUREMENTS AND MAIN RESULTS: Pulmonary artery occlusion pressure correlated with transmitral peak E-wave velocity (r =.46) and E/A ratio (r =.55). Pulmonary artery occlusion pressure inversely correlated with deceleration time of the transmitral E-wave (r = -.52), pulmonary venous peak S-wave velocity (r = -.37), and systolic fraction of the pulmonary forward flow (r = -.56). An E/A ratio >2 predicted a pulmonary artery occlusion pressure >18 mm Hg with a positive predictive value of 100%. A duration of pulmonary venous A-wave reversal flow exceeding the duration of the transmitral A-wave forward flow predicted a pulmonary artery occlusion pressure >15 mm Hg with a positive predictive value of 83%. A systolic fraction of the pulmonary venous forward flow <0.4 predicted a pulmonary artery occlusion pressure >12 mm Hg with a positive predictive value of 100%. CONCLUSION: Transmitral and pulmonary venous flow patterns measured by transthoracic Doppler echocardiography can be used to estimate the left ventricular filling pressure in critically ill patients.     

Mitral valve leaflet excursion velocity in the pediatric population: a comparable diastolic index to the color M-mode propagation velocity.

Color M-mode (CMM) Doppler flow propagation velocity (Vp) is a reliable diastolic index, but may be difficult to define. We hypothesized that because the valve is opened by flow, the anterior mitral leaflet excursion velocity (MEVApex ), interrogated from the cardiac apex, may be similar to the CMM-Vp. We investigated the MEVApex by apical M-mode echocardiography in 49 children and adolescents with normal echocardiograms, and compared it with the CMM-Vp and other indices. The mean CMM-Vp and MEVApex were similar (41.5 +/- 6 vs 40 +/- 5.7, respectively, mean +/- SD; P = .5) and correlated positively ( r = 0.71, P < .0001, Bland-Altman analysis). The peak velocity of mitral inflow (E wave) divided by the Vp (E/Vp) and E/MEVApex correlated well (2.54 +/- 0.58 vs 2.52 +/- 0.58, respectively, mean +/- SD; r = 0.857, P < .001, Bland-Altman analysis). The MEVApex is comparable with the CMM-Vp and the E/MEVApex with E/Vp. The Vp may be assessed either by CMM or conventional M-mode from the apex. In our experience, the latter is easier to do. Study in other populations is warranted.     

An evaluation of the use of new Doppler methods for detecting longitudinal function abnormalities in a pacing-induced heart failure model.

BACKGROUND: Doppler tissue echocardiography and color M-mode Doppler flow propagation velocity have proven useful in evaluating cross-sections of patients with left ventricular (LV) dysfunction, but experience with serial changes is limited. Purpose and methods: We tested their use by evaluating the temporal changes of LV function in a pacing-induced congestive heart failure model. Rapid ventricular pacing was initiated and maintained in 20 dogs for 4 weeks. Echocardiography was performed at baseline and weekly during brief pacing cessation. RESULTS: With rapid pacing, LV volume significantly increased and ejection fraction (57%-28%), stroke volume (37-18 mL), and mitral annulus systolic velocity (16.1-6.6 cm/s) by Doppler tissue echocardiography significantly decreased, with ejection fraction and mitral annulus systolic velocity closely correlated (r = 0.706, P <.0001). In contrast to the mitral inflow velocities, mitral annulus early diastolic velocity decreased steadily (12.3-7.3 cm/s) resulting in a dramatic decrease in mitral annulus early/late (1.22-0.57) diastolic velocity with no tendency toward pseudonormalization. The color M-mode Doppler flow propagation velocity also showed significant steady decrease (57-24 cm/s) throughout the pacing period. Multiple regression analysis chose mitral annulus systolic velocity (r = 0.895, P <.0001) and propagation velocity (r = 0.782, P <.0001) for the most important factor predicting LV systolic and diastolic function, respectively. CONCLUSIONS: Doppler tissue echocardiography and color M-mode Doppler flow could evaluate the serial deterioration in LV dysfunction throughout the pacing period. These were more useful in quantifying progressive LV dysfunction than conventional ehocardiographic techniques, and were probably relatively independent of preload. These techniques could be suitable for longitudinal evaluation in addition to the cross-sectional study.     

Mitral annulus velocity in the evaluation of left ventricular diastolic function in atrial fibrillation.

This study assessed the clinical utility of mitral annulus velocity in the evaluation of left ventricular diastolic function in patients with atrial fibrillation. Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. The clinical usefulness of conventional Doppler indexes is limited in atrial fibrillation because of the altered left atrial pressure and loss of synchronized atrial contraction. Mitral inflow and mitral annulus velocities were measured simultaneously with tau in 27 patients with nonrheumatic atrial fibrillation at the cardiac catheterization laboratory. Among deceleration time of mitral inflow, peak mitral inflow velocity (E), and peak diastolic mitral annulus velocity (E), only E correlated with tau (r = 0.51, P =.007). Prolonged tau (>/=50 ms) could be predicted by E <8 cm/s with a sensitivity of 73% (16 of 22) and a specificity of 100% (5 of 5). The E/E ratio correlated with left ventricular filling pressure (r = 0.79, P <.001). The E/E ratio of >/=11 could predict elevated left ventricular filling pressure (>/=15 mm Hg) with a sensitivity of 75% (9 of 12) and a specificity of 93% (14 of 15). Mitral annulus velocity is useful in the detection of impaired left ventricular relaxation and estimation of filling pressure even in patients with atrial fibrillation.     

Isovolumic relaxation flow propagation velocity in patients with diseases impairing ventricular relaxation.

To evaluate the propagation velocity of isovolumic relaxation flow within the left ventricle (IRFPV) associated with impaired ventricular relaxation, 49 patients with diseases known to impair ventricular relaxation (disease group) and 38 age-matched control subjects (control group) were studied. IRFPV was measured as the slope of the first aliasing velocity line segment of the isovolumic relaxation flow wave front in the color M-mode Doppler echocardiogram. Compared with the control group, the disease group had thicker interventricular septum and left ventricular posterior wall, more left ventricular mass, and lower early diastolic mitral annular velocity (8 +/- 3 vs 11 +/- 4 cm/s, P < .001), early (E) wave propagation velocity (47 +/- 16 vs 70 +/- 41 cm/s, P = .002), and IRFPV (193 +/- 149 vs 395 +/- 220 cm/s, P < .001). No matter in subgroup or whole population analysis, either the early diastolic mitral annular velocity or the E wave propagation velocity was selected as one of the determinants of IRFPV. In conclusion, diseases impairing ventricular relaxation may retard IRFPV.     

Analysis of the myocardial velocities in patients with mitral stenosis

BACKGROUND: Pure mitral stenosis (MS) affects left-ventricular performance as a result of myocardial and functional factors. We planned this study to evaluate the effect of MS on right- and left-ventricular functions using Doppler tissue imaging (DTI). METHODS: A total of 46 patients with an established diagnosis of MS (mean age: 41 +/- 11 years), and 40 age-matched healthy individuals (mean age: 40 +/- 9 years) were included in this study. Echocardiography equipped with DTI function was performed on each participant. The mitral valve area was measured. Myocardial velocities were recorded at 4 different sites (septum, lateral, anterior, and inferior) of the left ventricle, and the right-ventricular free wall annulus by DTI. The positive systolic velocity when the mitral and tricuspid ring moved toward the cardiac apex, and 2 negative diastolic velocities when the mitral annulus moved toward the base away from the apex (1 during the early phase of diastole and another in the late phase of diastole [A(m)]) were measured. The early diastolic velocity/A(m) ratio was calculated for each wall. The mean of systolic and diastolic myocardial velocities of the left ventricle was calculated. Patients with pure MS were compared with healthy participants, and the relationship of DTI variables with mitral valve area was evaluated. RESULTS: The myocardial velocities of the left ventricle indicating left-ventricular function were found to be significantly lower in patients with pure MS. Right-ventricular annulus velocities, on the other hand, were similar in both groups. A significant positive correlation could be established between mitral valve area and mean positive systolic velocity, A(m) of the left ventricle, and right-ventricular A(m) (r = 0.50, P <.001; r = 0.48, P =.001; r = 0.45, P =.002, respectively), whereas a significant negative correlation (r = -0.42, P =.004) was established for right-ventricular early diastolic velocity/A(m) ratio. CONCLUSION: This first study where pure MS was evaluated by DTI shows that MS affects left-ventricular performance on long axis. The results indicate that the decrease in left-ventricular performance is caused by both functional and myocardial factors.     

Left ventricular inflow propagation velocity at pulsed wave Doppler analysis: an index of relaxation.

To test whether left ventricular inflow propagation velocity at the pulsed wave Doppler analysis (IPVpw) is a useful noninvasive index of relaxation, 21 patients under coronary angiography for chest pain were included for simultaneous catheter-based and Doppler studies. IPVpw was derived through the application of range ambiguity, and the time constant of isovolumic left ventricular pressure decline (tau) was acquired by a previously described method. At baseline status, IPVpw correlated significantly with the peak negative dP/dt and tau ( r = -0.609, P = .003), but not with the peak velocity of transmitral early flow (E) wave. Sublingual application of nitroglycerin increased heart rate, decreased the transmitral E velocity and transmitral E-to-A velocity ratio, and prolonged the deceleration time of the transmitral E wave. However, there was no significant impact on IPVpw, peak negative dP/dt, or tau. IPVpw correlated with tau ( r = -0.533, P < .001) at the combined analysis of the data before and after nitroglycerin application. In conclusion, IPVpw is a preload-independent, noninvasive index of left ventricular relaxation.