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.     

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.     

Differentiation of left ventricular diastolic dysfunction, identification of pseudonormal/restrictive mitral inflow pattern and determination of left ventricular filling pressure by Tei index obtained from tissue Doppler echocardiography

BACKGROUND: Tei index obtained from tissue Doppler echocardiography (TDE-Tei index) has an inherent advantage of recording its systolic and diastolic components simultaneously on the same cardiac cycle. The aims of this study are to evaluate whether TDE-Tei index also exerts a correlation with left ventricular (LV) systolic and diastolic function and filling pressure and to see whether it can effectively identify the pseudonormal/restrictive mitral filling pattern. METHODS: Echocardiographic examination was performed in 243 consecutive patients. These patients were classified into three groups as normal, abnormal relaxation, and pseudonormal/restrictive groups according to the transmitral E/A-wave velocity (E/A), early diastolic velocity of lateral mitral annulus (Ea) and E/Ea. RESULTS: Standard Doppler indices of LV filling such as E, A, E/A, and E-wave deceleration time had a bimodal distribution, but Ea decreased and E/Ea and TDE-Tei index increased progressively with worsening of LV diastolic function. The sensitivity and specificity of TDE-Tei index>0.51 in the discrimination of pseudonormal/restrictive filling pattern were 85% and 96%, respectively. After stepwise multiple linear regression analysis, TDE-Tei index had a significant negative correlation with Ea (beta=-0.296, P<0.001) and ejection fraction (beta=-0.293, P<0.001) and positive correlation with E/Ea (beta=0.235, P=0.001). CONCLUSIONS: TDE-Tei index increased with worsening of LV diastolic function and can effectively identify the pseudonormal/restrictive mitral inflow pattern. It also correlated with the echocardiographic parameters of LV systolic and diastolic function and filling pressure. It suggests that TDE-Tei index is a simple and feasible marker in assessing global LV function.     

Evidence of left ventricular systolic and diastolic dysfunction by color tissue Doppler imaging despite normal ejection fraction in patients on chronic hemodialysis program

Background: Cardiovascular diseases are responsible for about half of deaths and are the major cause of mortality in hemodialysis patients. The aim of this study is to assess left ventricular (LV) longitudinal myocardial functions by color tissue Doppler imaging (TDI) in patients with chronic renal failure on a regular hemodialysis program. Methods: Thirty-one patients on a regular hemodialysis program (mean age 47 ± 12 years; 17 males, 14 females) were included into the study. Twenty-three healthy subjects (mean age 44 ± 8 years; 15 males, 8 females) were studied as a control group. The patients had been on maintenance hemodialysis for at least 1 month and hemodialysis sessions were three times per week. For color TDI, apical two- and four-chamber views of left ventricle were used. Sample volumes were placed on the mid-left ventricle in the inner half of the myocardium at the septum, lateral, inferior, and anterior walls. Peak LV strain, peak systolic strain rate, peak early diastolic strain rate, peak late diastolic strain rate, peak systolic tissue velocity, peak early diastolic tissue velocity, and peak late diastolic tissue velocity values were measured. Results: Mean peak LV strain, mean peak systolic strain rate, and mean peak systolic tissue velocity values were all lower in the hemodialysis group. Although mean peak late diastolic strain rate and mean peak late diastolic tissue velocity values were similar between the groups, mean peak early diastolic strain rate and mean peak early diastolic tissue velocity values were lower in the hemodialysis group. Conclusion: Patients with chronic renal failure on regular hemodialysis program show significant alterations at LV longitudinal myocardial function parameters assessed by color TDI.     

高同型半胱氨酸血症与高血压患者左室射血分数的相关性研究

目的探讨高同型半胱氨酸血症（Hhcy）与原发性高血压患者左室射血分数（LVEF）的相关性,评估左室收缩功能受损程度对预测高血压心衰的临床意义。方法选取高血压患者200例,其中非左室肥厚组（NLVH）100例,男性63例,女性37例,年龄（61．2x8．9）岁;左室肥厚组（LVH）100例,男性66例,女性34例,年龄（60．8±9．2）岁;对照组100例,男性65例,女性35例,年龄（60．9±9．5）岁。对所有受试者测定血清同型半胱氨酸（Hcy）水平及行超声心动图检查测量LVEF。结果对照组、NLVH组和LVH组血清Hey水平分别为（9．32±1．91）μmol／L、（20．92±3．28）p,mol／L和（29．60＋3．73）wmol／L,每两组间比较差异均有统计学意义（P〈0．01）。对照组、NLVH组和LVH组LVEF分别为（59．00±4．63）％、（40．70±1．87）％和（39．50±1．46）％,依次显著降低,差异有统计学意义（P〈0．01）。结论Hhcy与LVH呈正相关、与LVEF呈负相关,对预测高血压心衰,减少高血压心力衰竭的发生、发展有一定的临床价值。     

Noninvasive assessment of left ventricular end-diastolic pressure with tissue Doppler imaging in patients with mitral regurgitation

Background: The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity (E/Ea) is a widely used noninvasive tool to estimate left ventricular end diastolic pressure (LVEDP). The aim of this study was to explore whether E/Ea ratio was a reliable index for the estimation of LVEDP in patients with mitral regurgitation (MR). Methods: Sixteen patients with nonischemic MR (primary MR group; 6 male, 58 ± 12 years) 51 patients with ischemic MR (secondary MR group; 29 male, 63 ± 9 years) and 29 patients without MR (control group; 19 male, 53 ± 10 years) were consecutively included. The peak transmitral flow and mitral annular velocities during early diastole were measured. LVEDP was determined invasively by left heart catheterization. Results: Primary and secondary MR groups had significantly higher E/Ea ratios and LVEDP than control group. LVEDP significantly correlated with E/Ea ratio in patients with primary MR, but not in patients with secondary MR. Multiple regression analysis revealed that E/Ea ratio was an independent predictor of LVEDP in patients with primary MR. Ten patients with primary MR had LVEDP ≥15 mmHg. ROC analysis demonstrated cutoff values for E/Ea ratios as >10.5 for lateral mitral annulus (sensitivity: 80%, specificity: 66%, PPV: 80%, NPV: 66%) and as >14 for medial mitral annulus (sensitivity: 90%, specificity: 83%, PPV: 90%, NPV: 83%) to predict primary MR patients with LVEDP ≥15 mmHg. Conclusion: E/Ea ratio is still reliable in estimation of LVEDP in primary MR patients while it is not predictive for LVEDP in secondary MR patients. (Echocardiography 2011;28:633‐640)     

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 E/e filling index and right ventricular pressure in relation to applied international Doppler recommendations of left ventricular filling assessment.

AIM: A ratio>15 between the early diastolic pulsed Doppler velocities of the mitral inflow (E) and the basal left ventricular (LV) tissue (e) has been demonstrated to predict an elevated LV filling pressure (FP). An elevated LVFP implies an elevated right ventricular pressure (RVp). In order to investigate the sensitivity of the E/e filling index, we compared E/e and RVp, in their ability to identify a Doppler-assumed elevation of LVFP. METHODS AND RESULTS: Application of pulsed Doppler international recommendations grouped 134 patients with acute coronary syndromes (ACS) and 50 age- and sex-matched controls, according to LV filling: normal; delayed relaxation; an isolated pathological mitral-pulmonary venous-A-wave-duration difference; pseudo normal; or a restrictive filling pattern. An E/e>15 and an RVp>30 mmHg showed the following (%) sensitivity (32/94), specificity (95/76), positive (68/59), and negative (80/97) predictive values of a Doppler-assumed elevation of LVFP, in terms of either a pseudo normal or a restrictive filling pattern. CONCLUSION: The low sensitivity of E/e to detect a Doppler-assumed elevation of LVFP could limit its clinical usefulness as a single variable, in ACS. The high sensitivity and negative predictive value of RVp support its use as an additional LV filling variable in these patients.     

Assessment of left ventricular diastolic function and Tei index by tissue Doppler imaging in patients with Cushing's Syndrome

Background: The aim of this study was to assess left ventricular (LV) function and the Tei index by tissue Doppler imaging (TDI), and also to evaluate the relationship of serum cortisol level with the Tei index and LV function in patients with Cushing's Syndrome (CS). Methods: We prospectively evaluated 22 patients with CS and 23 control subjects. LV function was assessed by echocardiography. Early diastolic (Em), late diastolic (Am), peak systolic (Sm), mitral annular velocities, Em/Am, the Tei index, and E/Em were calculated by TDI. Mitral inflow velocities, color M-mode flow propagation velocity (Vp), relative wall thickness (RWT), and LV mass index (LVMI) were assessed by two-dimensional echocardiography. Result: Peak (E) velocity and the ratio of E to peak late (A) velocity (E/A) were lower in those with CS than in those without. Patients with CS had significantly higher RWT, IVRT, and LVMI than those controls. Vp was lower in the CS-patients than that in control subjects. Em and Em/Am were lower in patients with CS than those in controls. In patients with CS, the Tei index was significantly higher than control subjects. Conclusion: Serum cortisol level was positively correlated with the Tei index and E/Em ratio but negatively correlated with Em, Sm, and EF only in patients with CS. Serum cortisol level positively correlated with the Tei index and E/Em ratio but negatively correlated with Em, EF, and Sm. The parameters obtained from lateral mitral annulus by TDI can be used for identification of LV diastolic dysfunction in patients with CS.     

Diagnosis and treatment of heart failure with preserved left ventricular ejection fraction

Nearly six million people in United States have heart failure. Fifty percent of these people have normal left ventricular (LV) systolic heart function but abnormal diastolic function due to increased LV myocardial stiffness. Most commonly, these patients are elderly women with hypertension, ischemic heart disease, atrial fibrillation, obesity, diabetes mellitus, renal disease, or obstructive lung disease. The annual mortality rate of these patients is 8%-12% per year. The diagnosis is based on the history, physical examination, laboratory data, echocardiography, and, when necessary, by cardiac catheterization. Patients with obesity, hypertension, atrial fibrillation, and volume overload require weight reduction, an exercise program, aggressive control of blood pressure and heart rate, and diuretics. Miniature devices inserted into patients for pulmonary artery pressure monitoring provide early warning of increased pulmonary pressure and congestion. If significant coronary heart disease is present, coronary revascularization should be considered.     

AHFREF和AHFPEF患者远期预后情况观察

目的：观察射血分数降低的急性心力衰竭（Heart failure with reduced left ventricular ejection fraction, AHFREF）和射血分数保留的急性心力衰竭（Heart failure with preserved left ventricular ejection fraction, AHFPEF）远期预后,并分析影响预后的危险因素。方法 选取我院急诊科2013年3月至2014年3月收治的首次入院的急性心力衰竭患者280例,根据左室射血分数（left ventricular ejection fraction, LVEF）将患者分为两组：AHFREF组,LVEF<50%,n=152;AHFPEF组,LVEF≥50%,n=128例。记录所有患者性别、年龄、左心房扩大、左心室扩大、Killip分级为IV级和急性冠脉综合征（Acute coronary syndrome, ACS）等发病率,以及吸烟史、高血压和糖尿病等合并症、心房颤动等发生率,并记录血尿酸水平、超敏C反应蛋白（high-sensitivity C-reactive protein, hs-CRP）、脑钠肽前体（pro-brain natriuretic peptide, BNP）水平。所有患者均随访3年,记录随访期内心血管源性再住院率及病死率。采用非条件Logistic回归分析影响患者再住院的危险因素,并采用多因素Cox回归分析影响患者生存时间的预后因素。结果 AHFREF组患者左心室扩大、高血压、ACS、尿酸>30umol/l、BNP>220mg/l、hs-CRP>10mg/l发生率显著高于AHFPEF组（P<0.05）;AHFREF组患者因ACS再住院率及总再住院率均高于AHFPEF组（P<0.05）。非条件Logistic回归分析发现高血压、血尿酸、血BNP、血hs-CRP 是影响急性心力衰竭患者再住院的危险因素（P<0.05）。多因素Cox回归分析发现高血压、血尿酸、血BNP、血hs-CRP是影响患者生存期的影响因素（P<0.05）。结论 AHFREF患者3年内远期预后低于AHFPEF患者,高血压、高尿酸、高hs-CRP和高BNP水平是影响急性心力衰竭患者再住院和生存期的独立危险因素。     

多普勒组织成像检测肥厚型心肌病与高血压性心脏病的参数比较

目的初步探讨多普勒组织成像技术（TDI）对肥厚型心肌病（HCM）与高血压性心脏病鉴别诊断的临床价值。方法应用TDI技术对HCM患者、高血压性心脏病患者及正常人分别测量二尖瓣环收缩期峰值速度（Vs）、舒张早期峰值速度（Ve）及舒张晚期峰值速度（Va）。常规超声检查测得左室射血分数（LVEF）、左室短轴缩短率（FS）、二尖瓣口血流峰值速度E、A,计算E/A。结果HCM组、高血压性心脏病组各峰值速度均减低,与正常组比较差异有显著性意义（P<0.05）;HCM组部分心肌节段峰值速度与高血压性心脏病组比较有显著性差异（P<0.05）。结论TDI技术对HCM与高血压性心脏病鉴别诊断提供可行、实用的信息。     

The impact of aging on left ventricular longitudinal function in healthy subjects: a pulsed tissue Doppler study.

AIMS: To evaluate the influence of age on average values of pulsed tissue Doppler recorded at the septal and lateral mitral annulus in a population of healthy subjects and to propose reference values according to different age decades. METHODS AND RESULTS: Two hundred and forty-six healthy subjects (M/F = 160/86, mean age 40.9 years) underwent Doppler-echocardiography and pulsed tissue Doppler of the septal and lateral mitral annulus. S(m), E(m), A(m) peak velocities were measured at both the annular sides and average values obtained. The ratio of transmitral E peak velocity and average E(m) peak velocity (lateral E(m) + septal E(m)/2) was calculated as an index of left ventricular filling pressure. The population was divided into seven age decades: 10-19, 20-29, 30-39, 40-49, 50-59, 60-69 years and >70 years. E(m) was progressively reduced and A(m) increased with increasing age at both the annular sides as well as average values. S(m) reduction with advancing age was significant only at the lateral mitral annulus and as average values. Average E/E(m) ratio was particularly higher in the last three age decades. By multilinear regression analyses, age was the main independent predictor of average E(m), A(m) and E/E(m) ratio, while heart rate was the most important contributor to average S(m), with the additional contribution of age. CONCLUSIONS: Aging shows an independent impact on average tissue Doppler indexes of septal and lateral mitral annulus in normal subjects. Our data also provide reference values of tissue Doppler average variables for age decades.     

应用多普勒组织成像评价冠心病患者左心室舒张功能

目的 :探讨应用多普勒组织成像 （DTI）检测二尖瓣环运动速度评估冠心病左室舒张功能的临床应用价值。方法 :应用 DTI技术 ,对 5 3例冠心病患者和 48例正常对照者二尖瓣环运动速度进行测定 ,并与常规多普勒超声心动图检查结果对照分析。结果 :与正常组相比 ,冠心病患者舒张早期 DTI速度峰值 （Ve）显著减低 （P<0 .0 1） ,舒张早期与舒张晚期 DTI速度峰值的比值 （Ve/ Va）显著减低 （P<0 .0 5 ）。冠心病患者 Ve/ Va比值异常检出率显著高于二尖瓣血流 E/ A比值的异常检出率 （P<0 .0 5 ）。 Ve/ Va比值与 E/ A比值之间存在高度相关性 （P<0 .0 1）。结论 :DTI技术检测二尖瓣环舒张期运动速度参数可用于无创评价冠心病左室舒张功能 ,尤其对鉴别伪正常具有一定应用价值。     

Correlation of Tei index obtained from tissue Doppler echocardiography with invasive measurements of left ventricular performance

BACKGROUND: The aim of this study is to correlate Tei index obtained from tissue Doppler echocardiography (TDE-Tei index) defined as the ratio of the sum of isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) over the ejection time (ET) with invasive measurements of left ventricular (LV) performance. METHODS: Thirty-four patients who underwent an echocardiographic examination and cardiac catheterization were studied. Invasive measurements of peak +dp/dt, peak -dp/dt, and isovolumic relaxation constant of the left ventricle (tau) were obtained from a micromanometer-tipped catheter. RESULTS: After a multivariate analysis, TDE-Tei index had a negative correlation with ejection fraction (EF) (beta=-0.384, P = 0.046) and positive correlation with tau (beta= 0.397, P = 0.040). ET had a negative correlation with heart rate (beta=-0.446, P = 0.005) and positive correlation with EF (beta= 0.379, P = 0.015). ICT + IRT had a positive correlation with tau (beta= 0.512, P = 0.002). ICT/ET had a negative correlation with EF (beta=-0.657, P < 0.001) and positive correlation with peak early transmitral filling wave velocity (beta= 0.385, P = 0.001). IRT/ET had a positive correlation with tau (beta= 0.402, P = 0.018). CONCLUSIONS: TDE-Tei index exerts a correlation both with accepted indices of LV systolic and diastolic function acquired by cardiac catheterization. Hence, TDE-Tei index is a simple and feasible indicator in assessing overall LV function.