Effect of Preload Alternations on a New Doppler Echocardiographic Index of Combined Systolic and Diastolic Performance

The objective of the study was to assess the effect of preload alternations on a nongeometric Doppler index of combined systolic and diastolic myocardial performance (MPI). Doppler echocardiography was performed during Valsalva maneuver, passive leg lifting, and after sublingual administration of nitroglycerin in 50 healthy volunteers (group 1) and 25 patients (group 2) with previous myocardial infarction. MPI was significantly lower in group 1 (0.34 +/- 0.04) compared with group 2 (0.52 +/- 0.14), P <.0005. In group 1 MPI was significantly increased during preload manipulations (P =. 001). The largest change in MPI was induced by nitroglycerin (0.034 +/- 0.05). In group 2 no significant changes in MPI were found. In both groups peak E-wave velocity (P <.0005), E/A-ratio (P <.0005), and E-wave deceleration time (P <.0005) were found to change during preload alternations. In conclusion, we found in normal subjects and to a lesser extent in patients with previous myocardial infarction that MPI is influenced by preload.     

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.     

Preload-dependent variation of the propagation velocity in patients with congestive heart failure.

BACKGROUND: Although color Doppler M-mode propagation velocity (Vp) is preload-independent, the variation in Vp with the temporal variation of preload in the clinical setting has not been evaluated. Because left ventricular filling pressure changes dramatically with treatment of congestive heart failure (CHF), we hypothesized that preload-dependent variations in Vp occur with treatment of CHF. METHODS: We performed Doppler echocardiographic and hemodynamic evaluation in 24 patients with CHF (15 men, 62 +/- 10 years) at initial presentation (baseline study) and after CHF had improved with therapy (second study). RESULTS: The interval between the baseline and the second study was 48.6 +/- 21.5 hours. Vp decreased between the baseline study (41 +/- 5 cm/s) and the second study (28 +/- 5 cm/s, P <.0001). Only the change in pulmonary capillary wedge pressure (-8.3 +/- 3.3 mm Hg) between the baseline and second study was an independent predictor of the change in Vp (-12.5 +/- 5.9 cm/s) by stepwise linear regression (r = 0.68, P =.0002). CONCLUSIONS: Vp decreases significantly with decreases in pulmonary capillary wedge pressure with the treatment of CHF. The preload-dependent variation should be taken into account in the assessment of Vp in patients with CHF.     

Diagnosis of left-ventricular diastolic dysfunction in patients with predialysis chronic renal failure

AIM: To specify effectiveness of different methods for assessment of diastolic function in patients with pre-dialysis chronic renal failure (CRF). MATERIAL AND METHODS: Forty non-diabetic pre-dialysis CRF patients (20 males and 20 females, mean age 51 +/- 11 years) were studied. Serum creatinine was 209.3 +/- 117.4 mcmol/l. 19 patients had chronic heart failure (CHF) of NYHA class I-III. M-mode echocardiography and Doppler echocardiography were performed. Transmitral and pulmonary venous flows were assessed by Doppler echocardiography and the flow propagation velocity (Vp) was estimated by color M-mode Doppler echocardiography. The ratio of peak E-wave velocity of transmitral flow to Vp (E/Vp) was calculated. All the patients had preserved systolic function (ejection fraction > 45%). RESULTS: Interpretation of transmitral flow was difficult in 16 (40.0%) patients. During Valsalva's manoeuvre the E-wave peak velocities, the A-wave velocities and the ratio E/A were decreasing. However, we did not reveal any correlation between E/A and NYHA class of heart failure (r = 0.18; p = 0.32). Interpretation of pulmonary venous flow was possible only in 24 (60.0%) patients. Vp estimation by color M-mode Doppler echocardiography improved evaluation of diastolic function in 15 of 16 patients with problems of transmitral flow assessment. A negative correlation was revealed between NYHA class and Vp (r = -0.39; p = 0.013) and a positive correlation was between NYHA class and E/Vp (r = 0.45; p = 0.004). CONCLUSION: Vp assessed by color M-mode Doppler echocardiography improves the diagnosis of diastolic dysfunction in patients with chronic renal insufficiency. This method has an advantage over pulmonary venous flow investigation. The Valsalva's manoeuvre is low-effective for differential diagnosis of transmitral flow types.     

Structural-functional alterations in the heart affecting dynamics of transmitral blood flow during a hemodialysis session

AIM: To study dynamics of transmitral circulation (TMC) during a hemodialysis (HD) session in patients with chronic renal failure (CRF) regarding structural-functional alterations of the heart and baseline condition of the diastolic function of left ventricular (LV) myocardium. MATERIAL AND METHODS: Sixty one patients (34 females and 27 males, mean age 47 +/- 11 years) on programmed HD free of heart valvular disease, ischemic heart disease, acute myocardial infarction, atrial fibrillation. Before and after HD session the patients underwent echocardiography, including Doppler regime. RESULTS: Normal LV geometry was detected in 3 (4.9%) patients, concentric remodeling - in 9 (14.8%), concentric LV hypertrophy (LVH) - in 37 (60.7%), excentric LVH - in 12 (19.7%) patients. The ejection fraction was under 45% in 5 (8.2%) patients. Diastolic dysfunction of LV myocardium was found in 42 (68.9%) patients, TMC characteristic of slow relaxation was registered most frequently (47.6%). A pseudonormal type of TMC was recorded in 16 (38.1%) patients. HD did not change TMC significantly in patients with normal diastolic function (before HD E peak velocity was 88.7 +/- 19.8 cm/s, after - 80.0 +/- 24.6 cm/s, p > 0.05). In patients with initially disturbed relaxation the velocity of early diastolic flow (Vp) (color M-mode Doppler) increased (before HD, Vp was 67.6 +/- 17.1 cm/s, after - 72.9 +/- 15.7 cm/s, p < 0.05), E/Vp reduced (before HDm E/Vp was 1.2 +/- 0.4, after 1.0 +/- 0.4, p < 0.05). The subgroup with initially pseudonormal TMC showed decreased velocity in the E peak (before HD - 103.4 +/- 13.5 cm/s, after - 76.8 +/- 24.0 cm/s, p < 0.001). In restrictive TMC this velocity also decreased - 129.0 +/- 17.8 cm/s and 108.8 +/- 14.7 cm/s, p < 0.05, respectively). CONCLUSION: TMC alteration during a HD session depends more on initial type of diastolic dysfunction than on LV geometry. A HD session improves intracardiac hemodynamics in patients with pseudonormal TMC.     

Usefulness of early diastolic flow propagation velocity measured by color M-mode Doppler technique for the assessment of left ventricular diastolic function in patients with hypertrophic cardiomyopathy.

Flow propagation velocity (FPV) of left ventricular (LV) filling flow has been shown to be a useful index for the evaluation of LV diastolic function, which is relatively independent of preload in myocardial infarction and dilated cardiomyopathy, but the usefulness of FPV for hypertrophic cardiomyopathy (HCM) has not yet been determined. In 23 HCM patients and 26 control subjects, peak transmitral flow velocities in early diastole (E) and during atrial contraction (A), E/A ratio, deceleration time of E velocity, and isovolumic relaxation time were measured with the conventional Doppler technique, and FPV was measured from color M-mode Doppler images of LV filling flow. The time constant of LV isovolumic pressure decay (tau) was measured by a micro-manometer-tipped catheter in all HCM patients and 13 control subjects. Flow propagation velocity was significantly lower and deceleration time was significantly greater in HCM patients than in the control subjects, though no significant differences were observed in the other noninvasive indexes. Tau was significantly prolonged in HCM patients compared with that of control subjects (54+/-12 cm/s and 32 +/-7 cm/s, respectively; P<.0001). While the conventional indexes did not correlate with tau among the 36 patients in whom invasive studies were performed, FPV correlated well with tau (r = -0.76, P<.0001). Flow propagation velocity is a useful noninvasive index for the assessment of LV diastolic function in patients with HCM.     

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.     

Effect of cardiac resynchronization therapy on left ventricular diastolic filling pattern in responder and nonresponder patients

BACKGROUND: The aim of this study was to investigate the short- and long-term effects of cardiac resynchronization therapy (CRT) on left ventricular (LV) diastolic filling pattern and the relation between the diastolic filling pattern and the response to CRT. METHODS: Twenty-three patients with systolic heart failure and complete left bundle-branch block underwent implantation of biventricular pacemaker devices. In order to follow the changes in diastolic function, mitral inflow, pulmonary venous flow, and LV flow propagation (Vp) velocities were measured with pulsed-wave and color M-mode Doppler echocardiography 1 week before and 1 and 6 months after pacemaker implantation. At the 6-month follow-up, patients were divided into two groups according to their response to CRT defined as a relative increase in LV ejection fraction (LVEF) > or =25% versus baseline. RESULTS: After biventricular pacemaker implantation, significant clinical improvement was observed in all patients. Compared to baseline, the ratio of early-to-late peak velocities (E/A) decreased significantly at the 6th month (E/A ratio: from 1.5 +/- 0.9 to 0.8 +/- 0.5 at the 6th month (P = 0.02)). Pulmonary systolic flow to diastolic flow ratio (PVs/PVd) increased with CRT after 6 months (PVs/PVd ratio: from 0.9 +/- 0.4 to 1.3 +/- 0.7 at the 6th month (P = 0.02)). E/Vp ratio decreased significantly at the 1st and 6th month (E/Vp ratio: from 2.7 +/- 0.8 to 2 +/- 0.8 at the 1st (P < 0.002) and to 1.9 +/- 0.7 at the 6th month (P < 0.02)). In responders (n: 17, 74%), E wave and PVra velocity decreased, E-wave deceleration time increased, and E/Vp ratio improved significantly, whereas in nonresponders, changes in LV diastolic parameters remained insignificant. However, diastolic filling pattern improved significantly at the 1st and 6th month of CRT in both responders and nonresponders. CONCLUSION: CRT enhances diastolic filling patterns in both responder and nonresponder patients. This may be related to improvement in symptoms even in nonresponders who have a relative increase in LVEF <25%.     

Differentiation of abnormal relaxation pattern with aging from abnormal relaxation pattern with coronary artery disease in transmitral flow with the use of tissue Doppler imaging of the mitral annulus.

An abnormal relaxation pattern in transmitral flow velocity waveforms has been observed in older healthy subjects as well as in patients with heart disease. Accordingly, we investigated whether the hemodynamic differences between patients with coronary artery disease (CAD) with an abnormal relaxation pattern in transmitral flow (ratio of E-wave to A-wave velocities < 1.0) and healthy older subjects with an abnormal relaxation pattern can be distinguished with the use of mitral annular velocity (MAV) during early diastole. We measured MAV in the longitudinal direction of the heart during early diastole by M-mode color tissue Doppler imaging in 24 patients with atypical chest pain (defined as healthy subjects in this study) and 70 patients with CAD who underwent cardiac catheterization. In all patients a time constant of left ventricular pressure decay (tau) and the left ventricular (LV) end-systolic volume index were also measured. Twenty-one healthy subjects and 59 patients with CAD had an abnormal relaxation pattern in their transmitral flow. The age, heart rate, mean blood pressure, and ratio of E-wave to A-wave velocities were not different between the two groups. However, the tau was longer and the LV end-systolic volume index was greater in patients who had an abnormal relaxation pattern with CAD than in healthy subjects with an abnormal relaxation pattern. The MAV during early diastole was lower in the former than in the latter (5.8 +/- 1. 9 vs 9.8 +/- 1.9 cm/s, P <.001). Mitral annular velocity during early diastole by M-mode color tissue Doppler imaging can detect the differences in LV relaxation and LV systolic performance between the abnormal relaxation pattern with CAD and the physiologically abnormal relaxation pattern with aging, providing further information regarding the meaning of an LV abnormal relaxation pattern.     

彩色血流传播速度对二尖瓣置换术后左心室舒张功能的定量评估

目的 探讨彩色M型多普勒(CMM)评价二尖瓣置换术(MVR)后患者左室舒张功能的临床价值.方法 52例接受MVR术后3个月以上患者为病例组,另选取年龄、性别相匹配的30例正常人为对照组.测量左房室腔大小、机械瓣口流速、射血分数(EF)等常规超声心动图指标;应用CMM测量舒张期左室内彩色血流传播速度(Vp),计算二尖瓣位机械瓣口血流速度(E)与Vp比值(E/Vp);应用组织多普勒测量二尖瓣环舒张期峰值速度(Em),计算均值Em'和E/Em'.结果 ①MVR组Vp、Em较对照组明显减低,E/Vp、E/Em'较对照组明显增高,差异有统计学意义(P<0.001).E/Vp与E/Em'相关性良好,r=0.86,P <0.01;②Vp受左窜收缩功能和心律的影响,当EF≤50%或者心房颤动时,Vp减低更明显(P<0.01),而E/Vp受EF及心房颤动的影响较小(P>0.05);③绘制ROC曲线,以E/Vp≥2.00为最佳截断值,预测E/Em'≥15的敏感性为92.31%,特异性为83.65%,曲线下面积0.954.结论 CMM可用于评价MVR术后左室舒张功能;E/Vp与E/Em具有良好的一致性,可作为评价MVR术后左室舒张功能的有效指标.     

Effect of preload reduction by haemodialysis on new indices of diastolic function

Assessment of mitral annular motion diastolic velocities by M-mode or tissue Doppler imaging and the propagation velocity of early diastolic filling (Vp) by colour M-mode have been proposed as preload-independent indices of diastolic function. The aim of the present study was to determine the effects of preload reduction by haemodialysis on these new echocardiographic indices and to assess the relationship between these indices. The study group comprised 17 patients with chronic renal failure in sinus rhythm with normal left ventricular systolic function who underwent echocardiography 30 min prior to and 30 min following haemodialysis. Following dialysis there were significant reductions in weight (P<0.001), left atrial diameter (P=0.001), the peak Doppler velocity of early diastolic transmitral flow (P=0.005) and the ratio of Doppler velocities of early to late diastolic transmitral flow (P=0.02), consistent with a reduction in intravascular volume. There was no change after dialysis in early diastolic mitral annular velocity using M-mode (P=0.19) or tissue Doppler imaging from either the septal or lateral walls (P=0.88 and P=0.15 respectively), but there was a reduction in Vp after dialysis (55 to 49 cm/s; P=0.04). There were only weak correlations between Vp and the early diastolic mitral annular velocities (r<0.6 for all). We conclude that the assessment of diastolic function by the mitral annular early diastolic velocity appears to be preload-independent, that Vp may be affected by preload and that there is only a weak relationship between Vp and the early diastolic mitral annular velocity.     

Influence of preload alterations on parameters of systolic left ventricular long-axis function: a Doppler tissue study.

The study examined the influence of preload alterations on parameters of left ventricular (LV) long-axis function during systole. Doppler tissue echocardiography was performed in 32 healthy volunteers at rest who were placed in the Trendelenburg position after administration of 0.8 mg of nitroglycerin sublingually. In a 16-segment LV model, long-axis myocardial strain and systolic velocities were assessed. Isovolumic acceleration was assessed in the lateral mitral annulus. Mean LV strain and systolic velocity were unchanged during the different load conditions. In the mitral annulus, strain was also uninfluenced by preload alterations, whereas the peak systolic velocities seemed influenced by preload reduction. The isovolumic acceleration of the mitral annulus was found to be load dependent (enhanced preload 1.38 +/- 0.50 vs baseline 1.6 m/s2 +/- 0.60, P <.01; and preload reduction 2.18 +/- 0.65 m/s2, P <.01). In conclusion, LV long-axis strain and systolic velocities were not significantly influenced by load alterations, whereas myocardial systolic velocities and isovolumic acceleration in the lateral mitral annulus were significantly load dependent.     

Assessment of propagation velocity by contrast echocardiography for standardization of color Doppler propagation velocity measurements

BACKGROUND: Color Doppler propagation velocity (Vp) (color-Vp) has not yet been standardized, although it should be able to specifically reflect the intraventricular movements of left ventricular (LV) inflow. Because contrast echocardiography can depict a specified flow, we used this modality to standardize measurements of color-Vp of LV inflow. METHODS: We performed contrast echocardiographic examinations in 100 patients (70 men, 30 women; age 53 +/- 12 years). Four types of color-Vp were measured: by the flow wave front method and by aliasing method using 3 aliasing velocity levels based on the peak velocity of early diastolic flow of transmitral flow. We also determined contrast echocardiographic Vp by M-mode imaging of LV inflow (contrast-Vp). RESULTS: Contrast-Vp and all 4 types of color-Vp could be compared in 86 patients. Contrast-Vp was significantly lower than color-Vp ( P < .01), except for color-Vp measured at the aliasing level 50% > peak velocity of early diastolic flow >/= 40% (color-Vp 40). A close relationship was observed between contrast-Vp and color-Vp 40 ( r = 0.801, P < .0001). Contrast-Vp and color-Vp 40 showed high ability to detect abnormal transmitral flow patterns according to receiver operating characteristics curves (area under curve for contrast-Vp, 0.94; for color-Vp 40, 0.90). CONCLUSIONS: Our results should be useful in standardization of color-Vp measurement to specifically reflect propagation of the fluid elements derived from LV inflow, with ability to distinguish LV filling abnormalities.     

Color M-Mode Doppler Flow Propagation Velocity Is a Relatively Preload-Independent Index of Left Ventricular Filling

Standard Doppler indexes of transmitral filling vary in response to alterations in left ventricular (LV) relaxation or preload. To determine whether color M-mode Doppler flow propagation velocity (v_p ), a new index of LV relaxation, is affected by preload, we obtained LV volumes, standard Doppler filling indexes, and v_p in 20 patients at baseline, during Trendelenburg’s position, inverse Trendelenburg’s position, and after inhalation of amyl nitrite. LV end-diastolic volume decreased from 111 ± 41 mL at baseline and 116 ± 43 mL during Trendelenburg’s position, to 104 ± 40 during inverse Trendelenburg’s maneuver and 92 ± 33 mL after inhalation of amyl nitrite (P < .0001). Peak early filling velocity decreased from 79 ± 19 cm/s and 90 ± 20 cm/s to 73 ± 22 cm/s and 64 ± 20 cm/s, respectively (P < 0.0001). In contrast, no significant changes were found in v_p (48 ± 24 and 50 ± 26 cm/s vs 48 ± 25 and 48 ± 25 cm/s). We conclude that v_p is not affected significantly by preload. Thus v_p may provide a more reliable and independent assessment of LV relaxation. (J Am Soc Echocardiogr 1999;12:129-37.)     

Reproducibility of Doppler echocardiographic assessment of left ventricular diastolic function in multicenter setting.

BACKGROUND: Whether Doppler echocardiography allows reliable assessment of left ventricular (LV) diastolic parameters in multicenter studies is disputed. METHODS: To assess interstudy reproducibility of Doppler echocardiographic parameters of LV filling and relaxation in multicenter setting, two laboratories assessed Doppler parameters of LV filling and relaxation twice within 24 hours in 56 participants. The study sample included hospitalized patients, clinically healthy outpatients, and healthy volunteers. All studies were performed according to a standardized protocol, and read by a single reader. RESULTS: In the whole study sample the reproducibility of the assessment of the ratio between the peak velocities of the early (E) and late (A) LV filling waves (E/A), of the E wave deceleration time and atrial filling fraction, measured at the mitral valve leaflet tips, was good (intraclass correlation coefficients, rho: 0.89-0.76); the reproducibility performance of the same parameters measured at the mitral anulus was less good. The reproducibility of the assessment of the isovolumic relaxation time was good (rho: 0.81), and that of the E-wave propagation rate (E-Vp), by color M-mode, was excellent (rho: 0.96). The reproducibility of the ratio E wave peak velocity/E-Vp was also fairly good (rho: 0.87). The classification of E-Vp < 45 cm/s and E-Vp > or = 55 cm/s showed the highest between-study reliability performance (agreement index kappa = 0.92 and 0.83, respectively, both P < .001), followed by E/A at mitral leaflet tips >1.5 or <0.8 (kappa = 0.78 and 0.74, respectively, both P < .01), whereas the worst reliability performance was shown by isovolumic relaxation time < 60 milliseconds (kappa = 0.05, P = not significant). CONCLUSIONS: Standardized procedures for imaging and readings allowed good reliability of serial Doppler echocardiographic evaluations of LV filling and relaxation parameters in multicenter setting.     

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.     

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.     

Late left ventricular diastolic flow propagation velocity determined by color M-mode Doppler in the assessment of diastolic dysfunction.

BACKGROUND: Early color M-mode Doppler flow propagation (Ep) through the left ventricle (LV) has been proposed as a useful noninvasive index for assessing LV relaxation, whereas data concerning late velocity propagation (Ap) is lacking. METHODS: We studied 51 patients with delayed relaxation (group I) and 50 with pseudonormal filling pattern (group II). Another 51 aged-matched healthy persons served as the control group. RESULTS: Patients showed increased left atrial dimensions, atrial wave of the pulmonary vein flow, and Ap, and reduced LV ejection fraction, Ep, and Ep/Ap ratio compared with the control group. Patients in group II revealed increased left atrial dimensions (P =.001), atrial wave of the pulmonary vein flow (P <.001), and Ep/Ap ratio (P <.001), and reduced LV ejection fraction and Ap (P <.001) compared with group I. Regression analysis showed that the strongest independent variable distinguishing normal from pseudonormal filling pattern was the Ep/Ap ratio. CONCLUSION: Ap evaluation offers a new diagnostic diastolic index, especially in the field of the pseudonormal pattern where the separation from normal is difficult.     

Strain rate imaging for the assessment of preload-dependent changes in regional left ventricular diastolic longitudinal function.

BACKGROUND: Strain rate imaging is a new and intriguing way of displaying myocardial deformation properties by means of echocardiography. With high frame rate strain rate imaging we observed a spatial inhomogeneity in diastolic longitudinal strain rates in healthy persons. A base-to-apex time delay in diastolic lengthening could be seen both in early diastole and at atrial contraction. METHODS AND RESULTS: We investigated this consistent finding and its dependence on loading conditions in 20 healthy volunteers. Propagation velocities of lengthening of 91 +/- 31 cm/s (E-wave) and 203 +/- 11 cm/s (A-wave) at rest (equal to time delays of 104 +/- 29 ms and 56 +/- 24 ms, respectively) increased significantly to 101 +/- 27 cm/s (E) and 283 +/- 17 cm/s (A) with lifting the volunteers' legs. Applying nitroglycerin sublingually and sitting upright significantly decreased propagation velocities (E-wave 76 +/- 20 cm/s, A-wave 172 +/- 93 cm/s and E-wave 66 +/- 17 cm/s, A-wave 150 +/- 64 cm/s, respectively). Free lateral walls showed a lower propagation velocity than septal walls. CONCLUSION: We conclude that the propagation velocities of left ventricular lengthening waves are dependent on preload changes and increase with increasing preload.     

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.