Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy

This study assesses how the newer modalities of tissue Doppler echocardiography and color M-mode flow propagation compare with respiratory variation of Doppler flow in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. We studied 30 patients referred for further evaluation of diastolic function who had a diagnosis of constrictive pericarditis or restrictive cardiomyopathy established by diagnostic tests, including clinical assessment, magnetic resonance imaging, cardiac catheterization, endomyocardial biopsy, and surgical findings. Nineteen patients had constrictive pericarditis and 11 had restrictive cardiomyopathy. We performed 2-dimensional transesophageal echocardiography combined with pulsed-wave Doppler of the pulmonary veins and mitral inflow with respiratory monitoring, tissue Doppler echocardiography of the lateral mitral annulus, and color M-mode flow propagation of left ventricular filling. Respiratory variation of the mitral inflow peak early (peak E) velocity of > or =10% predicted constrictive pericarditis with 84% sensitivity and 91% specificity and variation in the pulmonary venous peak diastolic (peak D) flow velocity of > or =18% distinguished constriction with 79% sensitivity and 91% specificity. Using tissue Doppler echocardiography, a peak early velocity of longitudinal expansion (peak Ea) of > or =8.0 cm/s differentiated patients with constriction from restriction with 89% sensitivity and 100% specificity. A slope of > or =100 cm/s for the first aliasing contour in color M-mode flow propagation predicted patients with constriction with 74% sensitivity and 91% specificity. Thus, the newer methods of tissue Doppler echocardiography and color M-mode flow propagation are equivalent and complimentary with Doppler respiratory variation in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. The additive role of the new methods needs to be established in difficult cases of constrictive pericarditis where respiratory variation may be absent or decreased.     

Does Rapid Volume Loading During Transesophageal Echocardiography Differentiate Constrictive Pericarditis from Restrictive Cardiomyopathy?

BACKGROUND: Respiratory variation of the pulmonary venous (PV) peak flow velocities can be used to distinguish constrictive pericarditis (constriction) from restrictive cardiomyopathy (restriction). Rapid volume expansion has been used successfully to enhance diastolic pressure equalization in occult constriction. The effect of volume on the respiratory variation in constriction has not been studied previously. This study assessed the utility of volume in enhancing the PV respiratory variation of constriction to further separate it from restriction. METHODS: The study population consisted of 15 patients referred to the echocardiography laboratory for further evaluation of clinically suspected diastolic dysfunction. Pulsed-Doppler transesophageal echocardiography (TEE) of the left or right upper pulmonary vein and mitral inflow was performed with respiratory monitoring before and after infusion of 1 liter of normal saline over 5 to 10 minutes. The classification of patients as constriction (n = 8) or restriction (n = 7) was confirmed independently by cardiac catheterization or surgery. Peak velocities of the PV systolic and diastolic waves and the mitral inflow E were measured during inspiration and expiration. A mean of 3-6 respiratory cycles was obtained for each value before and after volume loading. The percent change from expiration to inspiration (%E) was calculated using the formula %E = expiration - inspiration / expiration. RESULTS: At baseline, patients with constrictive pericarditis can be separated reliably from those with restrictive cardiomyopathy based on a higher systolic/diastolic ratio and greater respiratory variation of their PV diastolic flow velocity. There were no complications in any patient due to volume expansion. Although the change from baseline to volume expansion was not statistically significant in either constriction or restriction, the %E of the PV diastolic wave became significantly higher in constriction than in restriction (P < 0.05). CONCLUSIONS: Rapid volume expansion is relatively safe during TEE and can be used for further separation of constrictive pericarditis from restrictive cardiomyopathy by significantly enhancing the respiratory variation of the PV diastolic flow velocity in constrictive pericarditis.     

Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography

Doppler ultrasound recordings of mitral, tricuspid, aortic, and pulmonary flow velocities, and their variation with respiration, were recorded in 12 patients with a restrictive cardiomyopathy and seven patients with constrictive pericarditis. Twenty healthy adults served as controls. The patients with constrictive pericarditis showed marked changes in left ventricular isovolumic relaxation time and in early mitral and tricuspid flow velocities at the onset of inspiration and expiration. These changes disappeared after pericardiectomy and were not seen in patients with restrictive cardiomyopathy or in normal subjects. The deceleration time of early mitral and tricuspid flow velocity was shorter than normal in both groups, indicating an early cessation of ventricular filling, but only patients with restrictive cardiomyopathy showed a further shortening of the tricuspid deceleration time with inspiration. Diastolic mitral and tricuspid regurgitation was also more common in the patients with restrictive cardiomyopathy. These results suggest that patients with constrictive pericarditis and restrictive cardiomyopathy can be differentiated by comparing respiratory changes in transvalvular flow velocities. In addition, although baseline hemodynamics in the two groups were similar, characteristic changes were seen with respiration that suggest differentiation of these disease states may also be possible from hemodynamic data.     

Differentiation of constrictive pericarditis and restrictive cardiomyopathy by radionuclide ventriculography

Patterns of left ventricular diastolic filling in five patients with unoperated constrictive pericarditis, the same five patients following pericardiectomy, five patients with restrictive cardiomyopathy, and 14 healthy control subjects were studied by radionuclide ventriculography. Patients with constrictive pericarditis had more rapid peak left ventricular filling rates (mean 5.62, range 4.23 to 7.32 end-diastolic volumes [EDV] per second) compared to control subjects 3.44, range 2.62 to 4.45 EDV/sec, p less than 0.05). Heart rate-corrected first one-third and first one-half diastolic filling fractions were greater in patients with preoperative constrictive pericarditis compared to members of the restrictive cardiomyopathy and control groups p less than 0.05). Following pericardiectomy, patients with constrictive pericarditis had significant decreases in peak filling rate and corrected filling fractions, and all diastolic filling measurements were indistinguishable from those of control subjects. These noninvasively obtained data indicate that patients with preoperative constrictive pericarditis have an increased rate of left ventricular early diastolic filling compared to patients with restrictive cardiomyopathy and control subjects, and that these findings return to normal following surgical removal of the pericardium.     

Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein

The diagnostic value of hepatic venous flow patterns was evaluated for constrictive pericarditis by pulsed Doppler. A characteristic flow pattern was assumed to be associated with the well-known atrial pressure curve. Thirteen patients with constrictive pericarditis were compared to 13 control subjects and to 25 patients with right ventricular pressure overload including 13 patients with tricuspid regurgitation. The characteristic finding in constrictive pericarditis was a W-wave pattern of flow velocities in the dilated hepatic veins, with abrupt reversal of flow late in systole and diastole before the A wave (100% specificity, 68% sensitivity). This depends, however, on the absence of tricuspid regurgitation (for its systolic component) or fast sinus rhythm (for its diastolic component). Additional diagnostic markers were systolic deceleration time of forward flow (40 to 130 ms) and systolic integral of flow velocities (4.3 to -4.0 cm) (sensitivity and specificity greater than or equal to 92%). In the presence of tricuspid regurgitation, diastolic deceleration time less than 150 ms and diastolic integral of flow velocities less than 6 cm were useful diagnostic signs. If combined, these criteria had 100% sensitivity and specificity for the diagnosis. Thus, pulsed Doppler assessment of flow velocities in the hepatic vein facilitates the diagnosis of constrictive pericarditis in clinical routine, using an auxiliary site with unlimited diagnostic access to the characteristic flow velocity pattern, which reflects right atrial pressure curve and filling abnormalities.     

Constrictive pericarditis versus restrictive cardiomyopathy: the role of Doppler echocardiography in differential diagnosis

Doppler ultrasound recordings of velocities of flow across the mitral and tricuspid valves and in the hepatic veins, and their variation with respiration, were recorded in seven patients with constrictive pericarditis and in six patients with restrictive cardiomyopathy. Deceleration of mitral and tricuspid flow was also evaluated during apnea. Color flow Doppler was performed in order to evaluate mitral and tricuspid regurgitation. Eight healthy adults served as controls. The patients with constrictive pericarditis showed higher peak diastolic velocities of mitral flow, as well as marked increase of velocity of flow at the onset of expiration and decrease at the onset of inspiration. Reciprocal respiratory variation of the velocities were also observed across the tricuspid valve. The patients with restrictive cardiomyopathy showed moderate or severe mitral and tricuspid regurgitation. They also showed shorter deceleration of flow across the mitral and tricuspid valves during apnea. The pattern of flow in the hepatic veins showed reversal during systole with accentuated reversion during inspiration. These results suggest that patient with constrictive pericarditis and restrictive cardiomyopathy can be differentiated by comparing Doppler echocardiographic data, along with changes induced by respiration.     

脉冲多普勒超声心动图评价糖尿病患者的左室舒张功能

本文应用脉冲多普勒超声心动图评价无心脏病或充血性心力衰竭临床表现的４６例糖尿病患者的左室舒张功能，并与４５例健康人对比，发现糖尿病患者的峰值速度Ｅ，峰值速度Ｅ与峰值速度Ａ之比及充盈分数值明显低于对照组，而峰值速度Ａ和等容舒张时间值则明显而于对照组，两组差异非常显著（Ｐ＜０．０１）。结果表明糖尿病患者左室舒张功能下降，主要为左室舒缓性减退，提示舒张早期左室充盈障碍和舒张晚期左室顺应性下降。     

Left ventricular filling in hypertrophic cardiomyopathy: a pulsed Doppler echocardiographic study

Abnormal left ventricular diastolic properties have been described in patients with hypertrophic cardiomyopathy. To evaluate the diastolic filling characteristics of the left ventricle in patients with this disease, pulsed Doppler echocardiography was used to study mitral flow velocity in 17 patients with hypertrophic cardiomyopathy (11 with and 6 without systolic anterior motion of the mitral valve) and 16 age-matched normal subjects. There were no statistically significant differences between patients with hypertrophic cardiomyopathy with and without systolic anterior motion with regard to ventricular septal thickness, left ventricular posterior wall thickness, left ventricular internal dimensions or the extent of hypertrophy evaluated by two-dimensional echocardiography. Mitral regurgitation was detected by Doppler echocardiography in all 11 patients with and in 2 (33%) of the 6 patients without systolic anterior motion of the mitral valve. Early and late diastolic peak flow velocity, the ratio of late to early diastolic peak flow velocity and deceleration of early diastolic flow were measured from Doppler mitral flow velocity recordings. There were no statistically significant differences in these four indexes between the patients with systolic anterior motion and normal subjects. In contrast, the patients with hypertrophic cardiomyopathy without systolic anterior motion showed lower early diastolic peak flow velocity, higher ratio of late to early diastolic peak flow velocity and lower deceleration of early diastolic flow compared with the patients with systolic anterior motion and normal subjects, suggesting impaired left ventricular diastolic filling.(ABSTRACT TRUNCATED AT 250 WORDS)     

Genesis of pericardial knock in constrictive pericarditis

A pericardial knock is a common finding in constrictive pericarditis. However, its origin has been uncertain. One hypothesis suggests that it is due to sudden deceleration of ventricular filling. To validate this hypothesis, left ventriculograms, phonocardiograms and external pulse recordings were obtained in seven patients with hemodynamic and pathologic findings of constrictive pericarditis and in seven normal subjects. Left ventriculographic silhouettes were digitized and left ventricular volumes were calculated by computer at 16 ms intervals. Curves of left ventricular volume versus diastolic filling time were constructed for each patient. Pericardial knock was recognized as an early high frequency sound recorded between 90 to 120 ms after the aortic closing sound and occurring at the trough of the Y descent of the jugular venous pressure tracing. The timing of the pericardial knock in five patients with constrictive pericarditis corresponded to a sudden and premature plateau of the diastolic left ventricular volume curve representing 85 ± 4 percent (mean ± standard deviation) of ventricular filling. The diastolic plateau was missing in two patients with constrictive pericarditis who had no pericardial knock. In these cases, the rate of ventricular filling was faster than normal in the first 20 percent of diastole.Thus, this study related pericardial knock to an abrupt plateau in the diastolic left ventricular volume curve, supporting the view that sudden cessation of ventricular filling generates the pericardial knock of constrictive pericarditis. Two mechanisms are proposed by which the filling plateau may produce the knock, and it is postulated that both ventricles may participate in the knock phenomenon.     

Prevalence and determinants of left ventricular diastolic filling abnormalities in an unselected hypertensive population

The independent contribution of age, sex, duration of hypertension, heart rate, clinic and ambulatory blood pressure and echocardiographic left ventricular mass to left ventricular diastolic filling abnormalities in essential hypertension was investigated in 250 subjects (145 untreated and unselected hypertensives and 105 healthy normotensive controls) undergoing Doppler and standard echocardiography and non-invasive 24-h ambulatory blood pressure monitoring. Late and early diastolic transmitral peak flow velocities and their ratio (all P less than 0.01), the rate of deceleration of early diastolic mitral flow (P less than 0.01) and the time of deceleration of early diastolic mitral flow (P = 0.018) were abnormal in the hypertensive group vs controls. None of these parameters significantly varied in the presence vs absence of LV hypertrophy. In the hypertensive group, the prevalence of abnormal age-corrected Doppler values varied up to 46% (up to 45.4% and 50% in the absence and presence of left ventricular hypertrophy, respectively; P = n.s.). In a stepwise multivariate regression analysis, age and average daytime or night-time ambulatory blood pressure showed a significant independent relationship with each of these Doppler indexes of left ventricular diastolic filling. Late transmitral peak flow velocity and the ratio of late to early peak flow velocity were also independently affected by the heart rate. Sex, duration of hypertension, clinic systolic and diastolic blood pressure and left ventricular mass index did not show any independent relationship to these Doppler parameters of left ventricular filling. In conclusion, Doppler abnormalities of diastolic transmitral blood flow were detected in up to 46% of patients in an unselected hypertensive population with a low prevalence (14.5%) of left ventricular hypertrophy. Age and ambulatory blood pressure, but not sex, duration of hypertension, clinic blood pressure and left ventricular mass itself, were the major independent determinants of these abnormalities.     

Tissue Doppler echocardiography

Tissue Doppler echocardiography (TDE) is a relatively recent addition to the diagnostic ultrasonographic examination. This is similar to routine Doppler ultrasonography to assess blood flow, but technologic features focus on lower velocity frequency shifts. Two techniques are used to assess myocardial function: pulsed TDE and color-coded TDE. A great deal of data has been generated on TDE over the last 5 years, and this review allows for only a small portion of these emerging data to be discussed. One clinical application is to assess peak systolic mitral annular velocity from the apical windows as an index of global ventricular function. The six-site average for peak systolic mitral annular velocity by the color-coded TDE method of greater than 5.4 cm/sec is predictive of an ejection fraction greater than 50% with an 88% sensitivity and a 97% specificity. An emerging application is to use pulsed-TDE to assess ventricular filling pressures. The mitral annular to inflow ratio (E/Ea) greater than 10 is predictive of a mean pulmonary capillary wedge pressure greater than 15 mm Hg with a 92% sensitivity and 80% specificity. Another application is to use peak early diastolic velocity to help differentiate constrictive pericarditis from restrictive cardiomyopathy. Peak early diastolic velocity is blunted with restrictive cardiomyopathy and preserved with constrictive pericarditis. These are just a few of the many evolving clinical applications of this new quantitative diagnostic ultrasonographic method.     

Impaired left ventricular diastolic filling in patients with familial amyloid polyneuropathy: a pulsed Doppler echocardiographic study.

To assess left ventricular diastolic filling in patients with amyloid heart disease 12 patients with familial amyloid polyneuropathy and 15 normal subjects were studied by pulsed Doppler echocardiography. None of the patients had clinical evidence of overt heart disease or restrictive cardiomyopathy and only two of them showed ventricular wall thickening. The peak flow velocity of rapid diastolic filling and the acceleration rate of early diastolic inflow were significantly lower in patients with familial amyloid polyneuropathy than in controls. The pressure half time was significantly longer in patients than in controls. In addition, the peak flow velocity during atrial contraction and the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity were significantly greater in patients than in controls. Although there were no significant correlations between measurements of diastolic filling and clinical findings in patients with familial amyloid polyneuropathy, the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity was significantly related to left ventricular posterior wall thickness. These findings suggest that in patients with cardiac amyloidosis without restrictive cardiomyopathy, abnormal left ventricular diastolic filling, manifested by a reduction in the rate and volume of rapid diastolic filling with enhanced atrial contraction, can be seen even in the early stage of the disease.     

Impaired left ventricular diastolic filling in patients with familial amyloid polyneuropathy: a pulsed Doppler echocardiographic study

To assess left ventricular diastolic filling in patients with amyloid heart disease 12 patients with familial amyloid polyneuropathy and 15 normal subjects were studied by pulsed Doppler echocardiography. None of the patients had clinical evidence of overt heart disease or restrictive cardiomyopathy and only two of them showed ventricular wall thickening. The peak flow velocity of rapid diastolic filling and the acceleration rate of early diastolic inflow were significantly lower in patients with familial amyloid polyneuropathy than in controls. The pressure half time was significantly longer in patients than in controls. In addition, the peak flow velocity during atrial contraction and the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity were significantly greater in patients than in controls. Although there were no significant correlations between measurements of diastolic filling and clinical findings in patients with familial amyloid polyneuropathy, the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity was significantly related to left ventricular posterior wall thickness. These findings suggest that in patients with cardiac amyloidosis without restrictive cardiomyopathy, abnormal left ventricular diastolic filling, manifested by a reduction in the rate and volume of rapid diastolic filling with enhanced atrial contraction, can be seen even in the early stage of the disease.     

Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography

This study evaluated the diagnostic role of early diastolic mitral annular velocity (E') by tissue Doppler echocardiography for differentiating constrictive pericarditis from restrictive cardiomyopathy (primary restrictive cardiomyopathy and cardiac amyloidosis). The study group consisted of 75 patients (53 men, 22 women; mean age 62 years, range 27 to 87). Of these, 23 patients had surgically confirmed constrictive pericarditis, 38 had biopsy-proved systemic amyloidosis and typical echocardiographic features of cardiac involvement, and 14 had primary restrictive cardiomyopathy. Standard mitral inflow characteristics were measured. Tissue Doppler echocardiography was used to measure E' at the septal annulus. E' was significantly higher in patients with constrictive pericarditis than in those with primary restrictive cardiomyopathy or cardiac amyloidosis (12.3 vs 5.1 cm/second, p <0.001). An E' cut-off value > or =8 cm/second resulted in 95% sensitivity and 96% specificity for the diagnosis of constrictive pericarditis. There was no overlap of E' between patients who had constrictive pericarditis and those who had cardiac amyloidosis. In a subgroup analysis of restrictive cardiomyopathy, E' of patients who had cardiac amyloidosis was significantly lower than that of patients who had primary restrictive cardiomyopathy (4.6 vs 6.3 cm/second, p <0.001). Thus, E' velocity can distinguish between constrictive pericarditis and restrictive cardiomyopathy with a specific cut-off value in patients with clinical and echocardiographic evidence of diastolic heart failure.     

Restrictive diastolic abnormalities identified by Doppler echocardiography in patients with thalassemia major

The consequences of transfusional iron overload on left ventricular diastolic filling have never been investigated systematically in patients with thalassemia major. In the present study, the pattern of left ventricular filling was assessed by Doppler echocardiography in 32 patients with thalassemia major (age, 17 +/- 5 years) who had not experienced symptoms of heart failure and had normal left ventricular systolic function. Data were compared with those obtained in 32 age-matched and sex-matched normal subjects. An abnormal Doppler pattern of left ventricular filling with increased flow velocity at mitral valve opening followed by an abrupt and premature decrease of flow velocity in early diastole was identified in the patients with thalassemia. Peak flow velocity in early diastole was increased in patients compared with controls (90 +/- 10 vs. 81 +/- 15 cm/sec; p less than 0.01), and rate of deceleration of flow velocity after the early diastolic peak and the ratio between the early and late (atrial) peaks of flow velocity were also increased (1,050 +/- 325 vs. 762 +/- 193 cm/sec2 and 2.7 +/- 0.7 vs. 2.2 +/- 0.5, respectively; p less than 0.001), whereas flow velocity deceleration time was reduced (97 +/- 22 vs. 119 +/- 19 msec; p less than 0.001). This Doppler pattern of diastolic filling is usually described as "restrictive" and reflects a decrease in left ventricular chamber compliance. A restrictive pattern of left ventricular filling was also identified in the subgroup of 16 study patients who had undergone optimal iron chelation therapy with deferoxamine.(ABSTRACT TRUNCATED AT 250 WORDS)     

M mode and Doppler echocardiographic assessment of left ventricular diastolic function in primary antiphospholipid syndrome.

BACKGROUND--High titres of serum antiphospholipid antibodies are a possible pathogenic factor for cardiac lesions in patients with systemic lupus erythematosus. OBJECTIVE--To test the hypothesis of a causal link between high titres of antiphospholipid antibodies in the serum and myocardial involvement in patients without systemic lupus erythematosus. PATIENTS AND DESIGN--18 patients with primary antiphospholipid syndrome (recurrent fetal loss, arterial and/or venous thrombosis, high titres of antiphospholipid antibodies, and no criteria for systemic lupus erythematosus) were prospectively studied by cross sectional, M mode, and pulsed Doppler echocardiography, and compared with 18 healthy controls. The pulsed Doppler indices of left ventricular diastolic function included isovolumic relaxation time and four mitral outflow indices: peak velocity of early flow, peak velocity of late flow, early to late peak flow velocity ratio, and rate of deceleration of early flow. Four computerised M mode indices were also measured: peak rate of left ventricular enlargement in diastole, peak rate of posterior wall thinning, peak velocity of lengthening of the posterior wall, and velocity of circumferential chamber lengthening. RESULTS--Compared with controls, patients with primary antiphospholipid syndrome had higher values for isovolumic relaxation time and peak velocity of late mitral outflow and lower values for early to late mitral peak outflow velocity ratio, rate of deceleration of early mitral outflow, peak rate of left ventricular enlargement in diastole, peak rate of posterior wall thinning, peak velocity of lengthening of the posterior wall and velocity of circumferential chamber lengthening. CONCLUSION--This abnormal pattern reflects an impairment of myocardial relaxation and filling dynamics of the left ventricle in patients with primary antiphospholipid syndrome who were free of any clinically detectable heart disease. These data suggest that high serum titres of antiphospholipid antibodies may be associated with subclinical myocardial damage.     

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

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

Demonstration of restrictive ventricular physiology by Doppler echocardiography

In patients with restriction of cardiac filling of various origins, cardiac catheterization has been traditionally used as part of the diagnostic evaluation to verify the presence of restrictive/constrictive hemodynamics. In an attempt to determine whether this "restrictive" physiology could be demonstrated noninvasively, 14 patients who had a history, physical examination, two-dimensional echocardiogram and catheterization data compatible with a restrictive myocardial process were studied with pulsed wave Doppler ultrasound. Forty normal subjects served as a control group. The Doppler ultrasound evaluation included measurement of peak mitral and tricuspid flow velocities and flow velocity integrals, mitral and tricuspid deceleration times and central venous flow patterns during apnea and inspiration. The flow velocity recordings across the mitral and tricuspid valves in patients manifesting restriction were markedly different from those in normal subjects, showing shortened deceleration times across both valves, which indicated both an abrupt premature cessation of ventricular filling and the presence of a diastolic dip-plateau contour in ventricular pressure recordings. In addition, abnormal central venous flow velocity reversals with inspiration and diastolic mitral and tricuspid regurgitation were frequently observed, also suggesting the reduced myocardial compliance characteristic of a restrictive myocardial process.     

Left ventricular Doppler characteristics in first-degree relatives of patients with hypertrophic cardiomyopathy

Left ventricular (LV) diastolic function may be affected early in patients with hypertrophic cardiomyopathy (HCM), regardless of the phenotypic expression of the disease. The aim of the present study was to detect whether LV diastolic performance, evaluated by conventional Doppler echocardiography, is impaired in first-degree relatives of patients with phenotypically expressed HCM, who had no clinical, electrocardiographic, or echocardiographic signs of the disease. Twenty-two young adults having the previously described characteristics comprised the study population and 22 sex- and age-matched healthy individuals served as controls. The 2 groups were compared according to several echocardiographic parameters and the following diastolic function indices: peak velocity of E wave, representing early filling; peak velocity of A wave, representing late filling; ratio of peak early to peak late velocity (E/A); deceleration time of E wave; and LV isovolumic relaxation time. Slower deceleration time of transmitral early filling in first-degree relatives of patients with HCM (192 +/- 31 vs 149 +/- 31 msec, p < 0.001) was the only variable that significantly differentiated the 2 groups. This study shows that in healthy persons with a family history of HCM, Doppler-derived mitral filling pattern shifted toward that observed in HCM and the slower deceleration time may serve as an early sign of disease development.     

Assessment of ventricular diastolic function.

A large number of patients suspected of having congestive heart failure have normal left ventricular systolic function and may, therefore, have primary diastolic heart failure. This diagnosis, however, should not be made unless there is also objective evidence of diastolic dysfunction, ie, signs of abnormal left ventricular relaxation and/or diastolic distensibility. The most useful noninvasive diagnostic approaches are the measurement of transmitral and pulmonary venous flow velocities by pulsed wave Doppler, and mitral annulus velocities by tissue Doppler echocardiography. In some patients, the assessment of intraventricular flow propagation by colour M-mode Doppler echocardiography provides additional information. Diastolic heart failure is most often due to coronary artery disease and/or hypertension; therefore, other noninvasive or invasive tests are needed to define the etiology of myocardial dysfunction. However, in the few patients who have constrictive pericarditis, the Doppler echocardiographic assessment of diastolic filling provides the most important clues to the etiology of the disease. Doppler echocardiographic assessment of left ventricular filling may also be used to obtain semiquantitative estimates of left ventricular diastolic pressure. Furthermore, left ventricular filling patterns, in particular, the deceleration time of early transmitral filling, are powerful predictors of patient prognosis. It is probably not cost effective to perform a comprehensive assessment of diastolic filling in every patient undergoing an echocardiographic examination. However, in selected patients, the assessment of diastolic filling provides information that is important for patient management.