Left Atrial Contribution to Left Ventricular Filling in Patients with Mitral Stenosis: Combined Analysis of Transmitral and Pulmonary Venous Flow Velocities

We recorded transmitral and pulmonary venous flow velocities using transthoracic continuous-wave and transesophageal pulsed Doppler echocardiography, respectively, in 36 patients with mitral stenosis who were in sinus rhythm to investigate the left atrial contribution to left ventricular filling in mitral stenosis. The mitral valve area was determined by transthoracic two-dimensional short-axis echocardiography. Patients were classified as having mild stenosis (± 1.5 cm², n = 17) or moderate stenosis (< 1.5 cm², n = 19). The mean pulmonary capillary wedge pressure and left atrial maximal diameter were significantly larger, and left atrial volume change during atrial contraction was significantly smaller in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, estimated from the transmitral flow velocity, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling, estimated from the pulmonary venous flow velocity, were significantly lower in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling were positively correlated with the mitral valve area and negatively correlated with the mean pulmonary capillary wedge pressure. These results suggest that the left atrial contribution to left ventricular filling in patients with mitral stenosis in sinus rhythm decreases as the severity of valve stenosis increases, and that analysis of the atrial systolic waves of the transmitral and pulmonary venous flow velocities provides important information for evaluation of left atrial systolic performance in patients with mitral stenosis.     

Mitral anulus motion. Relation to pulmonary venous and transmitral flows in normal subjects and in patients with dilated cardiomyopathy

The dynamics between mitral anulus motion, and, thus, motion of the base of the heart, and filling of the left atrium and ventricle were studied by Doppler echocardiography in 12 normal subjects and 28 patients with dilated cardiomyopathy. The normal motion of the mitral anulus is associated with two phases of inflow from the pulmonary veins. The first phase (J) of pulmonary venous inflow occurs during ventricular systole, concomitant with the descent of the mitral anulus toward the ventricular apex, the extent of which is 12.8 +/- 1.4 mm. The end of the descent of the anulus occurs at the cessation of aortic ejection. About 100 msec later, a rapid recoil of the mitral anulus toward the atrium coincides with the onset of transmitral filling. This rapid recoil contributes to the displacement of blood from the atria into the ventricles in early diastole. The second phase (K) of pulmonary venous flow begins in early diastole, with its peak occurring about 50 msec after the peak of transmitral flow. During atrial contraction, the mitral anulus moves slightly (2.4 +/- 0.7 mm) toward the atrium and then returns toward its initial position within 120 msec. This motion coincides with the A wave of transmitral flow. In patients with dilated cardiomyopathy, pulmonary venous flow and mitral anulus motion are markedly altered in comparison with normal subjects. In all patients, motion of the mitral anulus is either reduced or absent.(ABSTRACT TRUNCATED AT 250 WORDS)     

An echocardiographic assessment of atrial mechanical behaviour

Relations between movement of the atrioventricular ring and changes in left atrial and ventricular dimensions were studied by echocardiography and compared with apexcardiography and Doppler mitral flow velocity traces in 20 healthy controls and in patients with left ventricular hypertrophy (n = 28) or dilatation (n = 16). During left ventricular systole the atrioventricular ring, a structure common to ventricle and atrium, moved towards the ventricular apex, thus increasing left atrial volume. This action matched pulmonary venous return because it was in phase with the transverse left atrial dimension measured from aortic root to posterior left atrial wall. During early diastole, the mitral ring moved rapidly towards the atrium as transmitral flow accelerated. This requires a force directed from ventricle to atrium, likely to be the result of elastic recoil arising from compression of the ventricular myocardium or stretching of the atrial myocardium during ventricular systole. Two additional mechanisms of ventricular filling with atrial systole were recognised: (a) an increase in ventricular volume as the atrioventricular ring moved upwards and (b) transverse left ventricular expansion by pressure driven transmitral flow. The former is undetectable by Doppler from the apex; it accounted for 10% of ventricular filling in the healthy controls, but for significantly less in those with ventricular dilatation. In left ventricular hypertrophy, left ventricular filling was maintained by both mechanisms compensating for the reduced increase in volume early in diastole. Interactions between the atrium and ventricle are functionally important during ventricular systole, early diastole, and in atrial systole. They are not included in the traditional separation of atrial function into reservoir, conduit, and pump functions.     

An echocardiographic assessment of atrial mechanical behaviour.

Relations between movement of the atrioventricular ring and changes in left atrial and ventricular dimensions were studied by echocardiography and compared with apexcardiography and Doppler mitral flow velocity traces in 20 healthy controls and in patients with left ventricular hypertrophy (n = 28) or dilatation (n = 16). During left ventricular systole the atrioventricular ring, a structure common to ventricle and atrium, moved towards the ventricular apex, thus increasing left atrial volume. This action matched pulmonary venous return because it was in phase with the transverse left atrial dimension measured from aortic root to posterior left atrial wall. During early diastole, the mitral ring moved rapidly towards the atrium as transmitral flow accelerated. This requires a force directed from ventricle to atrium, likely to be the result of elastic recoil arising from compression of the ventricular myocardium or stretching of the atrial myocardium during ventricular systole. Two additional mechanisms of ventricular filling with atrial systole were recognised: (a) an increase in ventricular volume as the atrioventricular ring moved upwards and (b) transverse left ventricular expansion by pressure driven transmitral flow. The former is undetectable by Doppler from the apex; it accounted for 10% of ventricular filling in the healthy controls, but for significantly less in those with ventricular dilatation. In left ventricular hypertrophy, left ventricular filling was maintained by both mechanisms compensating for the reduced increase in volume early in diastole. Interactions between the atrium and ventricle are functionally important during ventricular systole, early diastole, and in atrial systole. They are not included in the traditional separation of atrial function into reservoir, conduit, and pump functions.     

Transesophageal Doppler echocardiographic assessment of pulmonary venous flow pattern in subjects without cardiovascular disease

This study was designed to assess pulmonary venous flow dynamics using transesophageal Doppler echocardiography. Under general anesthesia, we studied 54 surgical patients with no history or physical evidence of cardiac disorders. In all patients pulmonary venous flow was easily identified by transesophageal color flow mapping. Pulmonary venous flow pattern, which was obtained clearly in 85% (4654) of patients by transesophageal pulsed Doppler echocardiography, was tri- or quadriphasic. The first wave, which was often biphasic in elderly patients, occurred during ventricular systole (S wave). The second wave occurred in diastole during the early ventricular filling phase of mitral flow (D wave). The third wave was reverse flow toward the pulmonary vein during atrial contraction (A wave). The following variables were measured: the peak flow velocities of each wave (PFVs, PFVd, PFVa), and the ratio of PFVs to PFVd (PFV(S/D)). The PFVd correlated with age (r=–0.56, P<0.001), indicating age-related decrease. The PFV(S/D) correlated with age (r=0.61, p<0.001), indicating age-related increase. These results would indicate that the contribution of pulmonary venous flow during diastole to total pulmonary venous flow decreases with age.Our data suggest that age-related diastolic dysfunction of the left ventricle would affect pulmonary venous flow dynamics and that left atrial storage volume during ventricular systole would increase with age.     

Comparison of acoustic quantification and Doppler echocardiography in assessment of left ventricular diastolic variables.

OBJECTIVE--To assess the haemodynamic correlations of the waveforms of left ventricular area change obtained by automated boundary detection with newly developed acoustic quantification technology. DESIGN--The timing of events in the cardiac cycle was identified on the wave-form automated boundary detection and was correlated with the corresponding timing derived from pulsed wave Doppler flow velocity traces of the mitral valve and left ventricular outflow tract. The amounts of area change during the rapid filling phase and during atrial contraction were correlated with the time-velocity integrals of early and late diastolic ventricular filling obtained from Doppler tracings of the mitral inflow. SETTING--A university medical school echocardiography laboratory. SUBJECTS--16 healthy volunteers and 19 patients referred for echocardiographic studies. RESULTS--A significant correlation was found between the methods for measurement of the time from the R wave to mitral valve opening (r = 0.72, p < 0.01), isovolumic relaxation time (r = 0.62, p < 0.01), and ejection time (r = 0.54, p < 0.01). The change of total area that occurred during rapid filling and atrial filling phases measured from the acoustic waveform correlated with the time-velocity integrals of the early and late diastolic mitral valve inflow velocity derived from Doppler echocardiography (r = 0.60 and r = 0.80, respectively). CONCLUSION--The waveform of left ventricular area obtained by the automated boundary detection technique identifies the phases of the cardiac cycle and correlates with Doppler values of left ventricular diastolic function. Therefore, this new method of automated boundary detection has potential uses in the assessment of left ventricular diastolic function.     

Doppler evaluation of severity of mitral regurgitation: Relation to pulmonary venous blood flow patterns in an animal study

Objectives. This study examined the influence of regurgitant volume on pulmonary venous blood flow patterns in an animal model with quantifiable mitral regurgitation.Background. Systolic pulmonary venous blood flow is influenced by atrial filling and compliance and ventricular output and by the presence of mitral regurgitation. The quantitative severity of the regurgitant volume itself is difficult to judge in clinical examinations.Methods. Six sheep with chronic mitral regurgitation produced by previous operation to create chordal damage were examined. At reoperation the heart was exposed and epicardial echocardiography performed. Pulmonary venous blood flow waveforms were recorded by pulsed Doppler under color flow Doppler guidance using a Vingmed 750 scanner. The pulmonary venous systolic inflow to the left atrium was expressed as a fraction of the total inflow velocity time integral. Flows across the aortic and mitral valves were recorded by electromagnetic flowmeters balanced against each other. Pressures in the left ventricle and left atrium were measured directly with high fidelity manometer-tipped catheters. Preload and afterload were systematically manipulated, resulting in 24 stable hemodynamic states.Results. Simple logarithmic correlation between the regurgitant volume and size of a positive or negative pulmonary venous inflow velocity time integral during systole was good (r = −0.841). By stepwise linear regression analysis with pulmonary venous negative systolic velocity time integral as a dependent variable compared with the regurgitant volume, fractional shortening, left atrial νwave size, systemic vascular resistance and left ventricular systolic pressure, only contributions from νwave size and regurgitant volume (r = 0.80) reached statistical significance in determining pulmonary venous negative systolic flow.Conclusions. Evaluation of systolic pulmonary venous blood flow velocity time integral can give valuable information helpful for estimating the regurgitant volume secondary to mitral regurgitation.     

Transesophageal Pulsed Doppler Echocardiographic Study of Systolic Flow Velocity Patterns of the Pulmonary Vein in Patients with Atrial Fibrillation

We recorded pulmonary venous flow velocity in 27 patients with atrial fibrillation using transesophageal pulsed Doppler echocardiography to investigate the cycle length-dependent characteristics and background of early systolic reversal and second systolic forward waves. The study group consisted of 15 patients with mitral stenosis, 5 patients with left atrial myxoma, and 7 patients without underlying organic heart disease; they were compared with 20 normal controls in sinus rhythm. The mean pulmonary capillary wedge pressure was significantly greater in patients with mitral stenosis and left atrial myxoma than in normal controls and in patients with isolated atrial fibrillation. The mean peak velocity of the early systolic reversal wave was also significantly greater in patients with mitral stenosis and left atrial myxoma than in patients with isolated atrial fibrillation. The mean peak velocity of the second systolic forward wave was significantly lower in patients with mitral stenosis and left atrial myxoma than in controls and in patients with isolated atrial fibrillation. The preceding RR interval had significant negative correlations with the peak early systolic reversal velocity, left atrial pressure during closure of the mitral valve, and peak V wave height of the pulmonary capillary wedge pressure in patients with mitral stenosis and left atrial myxoma. In the same patient groups, the preceding RR interval had significant positive correlations with the peak second systolic forward velocity and amplitudes of the mitral annular and interatrial septal motions during ventricular systole. The variations in the peak velocities of the early systolic reversal and second systolic forward waves with the preceding RR interval were smaller in patients with more severe mitral stenosis. In conclusion, early systolic reversal waves of the pulmonary venous flow velocity reflect left atrial pressure, and the second systolic forward waves reflect left atrial filling. Both velocities vary with disease conditions or preceding RR intervals in atrial fibrillation.     

Characteristic Doppler echocardiographic pattern of mitral inflow velocity in severe aortic regurgitation

In symptomatic severe aortic regurgitation, left ventricular diastolic pressure increases rapidly, often exceeding left atrial pressure in late diastole. This characteristic hemodynamic change should be reflected in the Doppler mitral inflow velocity, which is the direct result of the diastolic pressure difference between the left ventricle and left atrium. Mitral inflow velocity was obtained by pulsed wave Doppler echocardiography in 11 patients (6 men, 5 women: mean age 53 years) with severe symptomatic aortic regurgitation and compared with normal values from 11 sex- and age-matched control subjects. The following Doppler variables were determined: velocity of early filling wave (E), velocity of late filling wave due to atrial contraction (A), E to A ratio (E/A), deceleration time and pressure half-time. In severe aortic regurgitation, E and E/A (1.13 m/s and 3.3, respectively) were significantly higher (p less than 0.001) than normal (0.60 m/s and 1.5, respectively). Deceleration time and pressure half-time (117 and 34 ms, respectively) were significantly shorter (p less than 0.001) than normal (203 and 59 ms, respectively). Late filling wave velocity (A) was not statistically different in the two groups, although it tended to be lower in the patient group (0.39 versus 0.50 m/s). Diastolic mitral regurgitation was present in eight patients (73%). M-mode echocardiography of the mitral valve, performed in 10 patients, showed that only 3 (30%) had premature mitral valve closure. In symptomatic severe aortic regurgitation, the Doppler mitral inflow velocity pattern is characteristic, with increased early filling wave velocity (E) and early to late filling wave ratio (E/A) and decreased deceleration time of the E wave.(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional assessment of the Fontan operation: combined M-mode, two-dimensional and Doppler echocardiographic studies

Combined M-mode, two-dimensional and Doppler echocardiographic studies were used to assess the postoperative status of 33 patients who had undergone the modified Fontan procedure. Twenty-four patients had surgical repair with use of a simple direct right atrium to pulmonary artery anastomosis. The remaining patients had repair with use of a prosthesis or associated Glenn shunt. Twenty-seven patients were studied early in the postoperative period (2 months or less) and the remaining patients were studied up to 6 years postoperatively. A total of 36 examinations were performed. Of the 33 patients, 13 had tricuspid atresia, 12 had double inlet left ventricle with hypoplastic right ventricular outlet chamber and 8 had complex lesions with atrioventricular canal, double outlet right ventricle or a hypoplastic ventricle. Postoperative assessment by M-mode and two-dimensional echocardiography demonstrated normal or mildly reduced ventricular function (ejection fraction greater than 40%) in 22 patients. In 24 patients, a "normal" flow pattern was observed in the pulmonary artery by pulsed Doppler echocardiography, with predominant diastolic flow and accentuation by atrial systole somewhat similar to the venous flow pattern observed in the superior vena cava. "Abnormal" flow patterns (disorganized systolic flow, absence of atrial waves and little or no increase with inspiration) were observed in nine patients with reduced ventricular function or residual shunt. Continuous wave Doppler study also demonstrated mild dynamic subaortic obstruction in two patients. Combined pulsed and continuous wave studies showed atrioventricular valve insufficiency in 10 patients. Follow-up studies revealed a satisfactory clinical course in most patients. Three patients died approximately 4 to 8 months after their Fontan operation.     

Echokardiographische Diagnostik der diastolischen Herzinsuffizienz

BACKGROUND: Left ventricular diastolic dysfunction can be diagnosed if clinical signs of heart failure and normal ejection fraction are found. Beside clinical signs of heart failure and criteria from catheterization studies like abnormal left ventricular relaxation, filling and/or compliance echocardiography provides valuable parameters for the assessment of diastolic dysfunction. ECHOCARDIOGRAPHIC DEGREES OF SEVERITY: By the use of various parameters diastolic dysfunction can be differentiated into four degrees of severity, which are of great prognostic importance. If more than one echocardiographic parameter is used, sensitivity for the assessment of diastolic dysfunction becomes nearly 100%. Conventional parameters include isovolumetric relaxation time (IVRT) measured by pulsed Doppler, the ratio of rapid filling and atrial filling velocity (E/A), deceleration time of rapid mitral inflow as well as the ratio of systolic and diastolic pulmonary venous flow velocities. In patients with signs of diastolic heart failure and a normal E/A ratio pulmonary venous flow pattern can help to unmask "pseudonormalization" as the transition from abnormal relaxation to restriction. These parameters, however, are preload-dependent and do not provide intrinsic left ventricular properties. Even in atrial fibrillation, left ventricular filling pressure can be assessed. NEW METHODS: Two novel approaches, color Doppler M-mode of left ventricular inflow and tissue Doppler of the mitral annulus, are relatively preload-independent and allow direct estimation of relaxation and filling pressure. By the means of real-time 3-D echocardiography we developed a new method for the non-invasive assessment of rapid filling rate (PFR), thereby completing the echocardiographic approaches to determine diastolic dysfunction. CONCLUSION: The broad spectrum of approaches available today makes echocardiography the first choice for the assessment of diastolic dysfunction.     

L wave in echo Doppler

62-Year-old female presented with progressive dyspnea NYHA class III for six months. Echocardiography showed normal left ventricular (LV) systolic function, mild biatrial enlargement, an L wave in pulse wave Doppler at mitral inflow and in M mode echocardiography across mitral valve. Tissue Doppler imaging at medial mitral annulus showed an L′ wave in mid diastole in addition to E′ and A′ wave. An L wave in pulse wave Doppler and M mode echocardiography represents continued pulmonary vein mid diastolic flow through the left atrium in to LV across mitral valve after early rapid filling. Presence of an L′ wave in these patients associated with higher E/E′ is indicative of advance diastolic dysfunction with elevated filling pressures.     

Asynchronous atrioventricular valve opening as it relates to right to left interatrial shunting in the normal newborn

The opening of the tricuspid valve and the onset of right ventricular filling precede the opening of the mitral valve and the onset of flow in the normal adult. Sixty-five studies of atrioventricular flow with range-gated pulsed Doppler echocardiography, performed on 32 normal neonates, consistently demonstrated the reverse sequence. Further investigation showed that at the time of mitral valve opening, while the tricuspid valve was still closed, the valve of the foramen ovale began to bow posteriorly into the left atrium and remained posteriorly bowed for most of diastole. The magnitude of posterior bowing varied among the neonates but, concomitant with the more prominent grades of posterior bowing, right to left shunting across the foramen ovale was demonstrated on color flow mapping. Ultrasound studies in the normal fetus also revealed earlier opening of the mitral valve, bowing of the valve of the foramen ovale into the left atrium and right to left shunting across the foramen ovale. These findings indicate that in the normal immature heart isovolumic ventricular relaxation is completed earlier on the left than on the right side and that left ventricular compliance appears to be greater than right ventricular compliance. The relation of left and right ventricular compliance in the adult is different from that in the normal immature heart. Whereas systemic and pulmonary vascular resistance and pressure levels change rapidly in the newborn period, ventricular compliance matures over a longer period of time. As a result of the differential maturity, for a variable period of time in the normal neonate, a left to right ductal shunt coexists with a right to left atrial shunt.     

Atrial contraction is an important determinant of pulmonary venous flow

Pulmonary venous flow has two phases (systolic and diastolic) in normal subjects when studied by pulsed Doppler echocardiography. Only one phase of pulmonary venous flow (diastolic) was observed in six patients without synchronous atrial contraction (four patients with atrial fibrillation and two with complete atrioventricular [AV] block). This pattern reversed to normal (biphasic) when AV synchrony was reestablished by cardioversion to sinus rhythm in patients with atrial fibrillation and by AV sequential pacing in patients with complete AV block. Thus, both atrial and ventricular contraction and relaxation are important determinants of pulmonary venous flow.     

Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation

Background: The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling. Hypothesis: The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation. Methods: We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm. Results: Mean pulmonary capillary wedge pressure, V-wave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V-wave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy. Conclusion: Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.     

Doppler echocardiographic features of the atrial and ventricular filling modes and their significance in restrictive myocardial diseases

The filling modes into the right atrium and both ventricles were observed using pulsed Doppler echocardiography in six cases of restrictive myocardial diseases, and these were compared with those of 13 cases of constrictive pericarditis, six cases of lone atrial fibrillation and 16 healthy subjects. Special attention was paid to the mechanical properties of the cardiac walls which might be reflected in the filling modes. 1. In the restrictive cases, right atrial filling from the superior caval vein during ventricular systole was reduced in velocity and duration, but the atrial filling during ventricular diastole was not appreciably changed. This flow pattern was similar to that of lone atrial fibrillation, indicating reduced distensibility or impaired contraction and ejection fraction of the right atrium. In constrictive pericarditis, the right atrial filling time was shortened both in ventricular systole and diastole, reflecting stiffening of the pericardium. 2. In the restrictive cases, the first half of the left ventricular rapid filling wave was steep and the skirt of the descending limb was prolonged, while there was no such tendency in the right ventricle. In constrictive pericarditis, the rapid filling time was shortened in the right ventricle, and was not significantly changed in the left ventricle. 3. The differences in the atrial and ventricular filling patterns between restrictive myocardial disease and constrictive pericarditis may serve to distinguish these two disease entities.     

Assessment of pulmonary blood flow after total cavopulmonary shunt operation and the modified Fontan procedure for univentricular heart

Pulsed Doppler echocardiography was utilized to elucidate the characteristics of pulmonary arterial (PA) blood flow in five patients without apparent pumping chambers in their right heart circulation after right heart bypass surgery for univentricular heart. Two of these patients underwent total cavopulmonary shunt operation, in which the total systemic venous return drained directly into the PA, bypassing the right atrium and ventricle. Three underwent the modified Fontan procedure with atrial partition, in which the right-sided atrium was reconstructed merely as a pathway from the vena cava to the PA, and atrial contraction was nearly entirely excluded. The flow pattern in the PA was biphasic and forward in all five patients. Pulmonary regurgitation was not observed in any of the patients. The first phase of PA flow had its peak during atrial systole; the second, during ventricular systole. Simultaneous observation of PA flow and pressures demonstrated an inverse relation between PA flow and pressure. Pulmonary venous (PV) blood flow pattern was also biphasic and similar to the PA blood flow pattern with time lags. In conclusion, in cases without pumping right heart chambers, PA flow reflects PV flow resulting from contraction and relaxation of the left atrium and ventricle.     

Doppler transmitral and pulmonary venous flow in young orienteers and sedentary young adults

Doppler filling indices may provide important information on left ventricular diastole and possibly diastolic adaptation in endurance athletes. We therefore undertook a comparative study to obtain reference values for transmitral and pulmonary venous Doppler flow velocities and to characterize differences between young orienteers and young sedentary adults. Seventy-six elite orienteers (42 female and 34 male; 17-30 years old) and 61 sedentary young subjects (32 female and 29 male; 17-33 years old) underwent echocardiography. No significant differences between the athletes and sedentary controls regarding peak transmitral flow were found, although the athletes had significantly higher peak pulmonary flow velocity during diastole than the sedentary controls (0.69+/-0.13, 0.61+/-0.10, 0.78+/-0.12, and 0.57+/-0.09 m/sec for female athletes, female sedentary controls, male athletes, and male sedentary controls, respectively). Because no significant differences were revealed in the transmitral flow velocities between the athletes and the sedentary subjects, the relative force between the left atrium and the left ventricle should not diverge during early filling. An increase in pulmonary venous pressure or a decrease in left atrial pressure can augment the force between the pulmonary veins and the left atrium. A rise in pulmonary venous pressure is a hemodynamically unlikely adaptation in endurance athletes; therefore, to maintain the same transmitral pressure with an assumed lower left atrial pressure, the data suggest a more rapid relaxation and an improved left ventricular elastic recoil, which would enable the athletes to achieve a more rapid negative left ventricular pressure change during early filling.     

Diastolic forward blood flow in the pulmonary artery detected by Doppler echocardiography

The etiology of diastolic motion of the pulmonary valve seen on the M-mode echocardiogram has been the subject of much debate. To further investigate diastolic events in the pulmonary artery, the patterns of diastolic pulmonary artery blood flow velocity were studied using pulsed Doppler echocardiography in patients with a normal heart. Two diastolic waveforms were found, one in early diastole related to passive filling of the right ventricle and one in late diastole related to atrial contraction. These waveforms were also related to the two recognized phases of diastolic pulmonary valve motion detected by M-mode echocardiography. The presence of biphasic diastolic blood flow in the pulmonary artery was confirmed by electromagnetic flow velocimetry in four additional patients with various cardiac diseases and normal right heart pressures. It is concluded that both atrial contraction and passive right ventricular filling produce blood flow in the pulmonary artery.