Lack of Association between Obesity and Left Ventricular Systolic Dysfunction

Background: Previous studies have demonstrated that obesity is one of the risk factors for congestive heart failure (CHF). By analyzing a large database, we investigated any association between body mass index (BMI) and left ventricular (LV) systolic dysfunction. Methods: We retrospectively analyzed 24,265 echocardiograms performed between 1984 and 1998. Fractional shortening (FS) and BMI were available for 13,382 subjects in this cohort which were used for data analysis. FS was stratified into four groups: (1) FS > 25%, (2) FS 17.5–25%, (3) FS 10–17.5%, and (4) FS < 10%. Furthermore, we also used final diagnosis that was coded by the reading cardiologist as mild, moderate, and severe LV dysfunction separately for data analysis. BMI was divided into four groups: BMI < 18.5 kg/m² (underweight), 18.5–24.9 kg/m² (normal), 25–30 kg/m² (overweight), and >30 kg/m² (obese). Results: There was no association between different BMI categories and LV systolic function. The prevalence of mild, moderate, or severely decreased LV function (based on FS or subjective interpretation of reading cardiologists) was equally distributed between the groups. Obese patients (BMI > 30%) had normal FS of >25 in 16.9%, mildly decreased FS in 18%, moderately decreased FS in 18.4%, and severely decreased FS in 20.1% P = ns. Conclusion: Our study is consistent with previous trials suggesting that obesity is not related to systolic LV dysfunction. The underlying mechanism for the occurrence of congestive heart failure in obese patients needs further investigation.     

Invasive evaluation of left ventricular diastolic performance

Diastole can be divided into four phases: 1. isovolumic relaxation; 2. early filling; 3. diastasis; and 4. atrial systole. The amount of left ventricular (LV) filling that occurs during each of these phases depends on: 1. myocardial relaxation; 2. the passive characteristics of the LV; 3. the characteristics of the left atrium, pulmonary veins and mitral valve; and 4. the heart rate. When diastolic function is normal, the net effect of these factors results in LV filling sufficient to produce an adequate cardiac output, while mean pulmonary venous pressure is maintained below 12 mm Hg. Diastolic dysfunction is normally manifest as pulmonary congestion. In the absence of systolic dysfunction, abnormal diastolic performance is usually due to abnormal relaxation and/or changes in the passive LV characteristics, external compression or disease of the mitral valve and left atrium. Invasive studies can quantify the rate of myocardial relaxation from the time course of the fall of LV pressure during isovolumic relaxation and the passive LV properties from the LV diastolic pressure-volume relation. In addition, frame-by-frame analysis of contrast ventriculography and conductance determination of LV volume can quantify the pattern of LV diastolic filling. Normally, at rest, most LV filling occurs early in diastole. Conditions that produce diastolic dysfunction, such as LV hypertrophy and ischemia, are associated with reduced early diastolic filling and an augmented importance of atrial systole. It is important to recognize that such patterns can occur in patients without clinically apparent diastolic dysfunction and in normals if left atrial pressure is sufficiently elevated. Furthermore, a normal pattern can occur in patients with severe diastolic dysfunction. Reduced early diastolic filling in the absence of pulmonary congestion indicates the loss of diastolic reserve, since the left atrium is being used as a booster-pump. This pattern of diastolic filling in a patient with symptoms of pulmonary congestion suggests diastolic dysfunction, even if systolic LV performance is normal.     

Determinants of right ventricular failure in patients admitted with acute left heart failure

Pulmonary hypertension, which may lead to right ventricular (RV) failure, increases with left ventricular (LV) diastolic dysfunction severity. The prevalence and determinants of RV failure were analyzed in 120 patients admitted with acute left heart (LH) failure. Patients were divided into RV failure (n=50) and non-RV failure (n=70) groups. The prevalence of RV failure was found to be 42%. In both groups, two thirds of the patients had isolated LV diastolic dysfunction and the rest had combined LV systolic and diastolic dysfunction. Patients in the RV failure group were characterized by higher LV diastolic grade (2.2 ± 0.6 vs 1.84 ± 0.7; P=.0070), pulmonary artery systolic pressure (PASP; 57.8 ± 15.3 vs 50.14 ± 12.1 mm Hg; P=.0028), right atrial enlargement (92% vs 25.7%; P=.000001), and more-than-moderate tricuspid regurgitation (58% vs 27.1%; P=.0006). RV failure is a frequent finding in patients with advanced LH failure. It is strongly associated with the severity of LV diastolic dysfunction and the severity of PASP.     

Prognostic role of left atrial volume in elderly patients with symptomatic stable chronic heart failure: comparison with left ventricular diastolic dysfunction and B-type natriuretic peptide

BACKGROUND: Left atrial (LA) volume and B-type natriuretic peptide (BNP) represent powerful outcome predictors in patients with heart failure (HF).Aim: To assess the comparative prognostic role of LA volume (indexed to body surface area, LAVi), left ventricular diastolic dysfunction (LVDD) and BNP levels on long-term outcome in patients with symptomatic but stable chronic HF. methods: We studied consecutively 46 patients with symptomatic stable chronic HF (73 +/- 10 years, 30 men), in sinus rhythm, without significant valvular disease. Echocardiographic measurements included: LV mass, LV volumes and ejection fraction, and LAVi. LVDD was graded using a comprehensive Doppler algorithm. Blood taken before echocardiography was assayed for BNP levels. Primary end point was combined: all-cause mortality and hospitalization for worsening HF. RESULTS: During 20 +/- 14 months of follow-up 19 events occurred: 8 deaths, and 11 hospitalizations for HF. In univariate analyses LAVi, LVDD, BNP levels, LV ejection fraction, LV volumes, and LV mass were significant outcome predictors (P < 0.05). At multivariate regression LAVi was the only independent predictor of outcome (hazard ratio: 1.03 per 1 ml/m(2) increase, 95% CI: 1.01-1.06, P = 0.02). CONCLUSION: Although directly related to LVDD and to BNP levels, only LAVi emerged as an independent outcome predictor in this cohort of elderly patients with symptomatic stable chronic HF.     

Relation of left atrial volume to B-type natriuretic peptide levels in patients with stable chronic heart failure

This study assessed the relation between B-type natriuretic peptide (BNP) and echocardiographic indexes of left ventricular (LV) filling pressure in 53 patients with stable heart failure and without significant valvular dysfunction. Left atrial volume indexed to body surface area (LAVi), an indicator of chronic LV filling pressure, was correlated with BNP (r = 0.692, p <0.001) and was the strongest independent predictor of elevated levels in this cohort. LAVi was also the best predictor of BNP >or=100 pg/ml, with an area under the receiver-operating characteristic curve of 0.85 (95% confidence interval 0.74 to 0.96, p <0.001). Using the optimal cutoff of >31 ml/m(2), LAVi had a sensitivity of 92% and a specificity of 65% for BNP >or=100 pg/ml. Patients with LAVi >31 ml/m(2) had a median BNP of 122 pg/ml, compared with 21 pg/ml in patients with LAVi 相似文献   

Left Ventricular Untwisting in Restrictive and Pseudorestrictive Left Ventricular Filling: Novel Insights into Diastology

Background: Conceptually, an ideal therapeutic agent should target the underlying mechanisms that cause left ventricular (LV) diastolic dysfunction. The objective of our study was to gain further insight into the mechanics of diastology by comparison of LV untwisting measured by speckle tracking echocardiography (STE) in young healthy adults with normal and “pseudorestrictive” LV filling, and dilated cardiomyopathy (DCM) patients with “true restrictive” LV filling. Methods: The study comprised 20 healthy volunteers with a Doppler LV‐inflow pattern compatible with restrictive LV filling but a diastolic early phase filling velocity/early diastolic velocity of the mitral annulus (E/Em) ratio <8 (“pseudorestrictive”), 20 for age and gender‐matched healthy volunteers with normal LV filling and an E/Em ratio <8, and 10 DCM patients with “true restrictive” LV filling and an E/Em ratio >15. LV untwisting parameters were determined by STE. Results: Compared to healthy subjects, DCM patients had decreased peak diastolic untwisting velocity (−62 ± 33 degrees/s vs −113 ± 25 degrees/s, P < 0.01) and untwisting rate (−15 ± 9 degrees/s vs −51 ± 24 degrees/s, P < 0.01). Compared to healthy subjects with normal LV filling, healthy subjects with “pseudorestrictive” LV filling had increased peak diastolic untwisting velocity (−123 ± 25 degrees/s vs −104 ± 30 degrees/s, P < 0.05) and untwisting rate (−59 ± 23 degrees/s vs −44 ± 22 degrees/s, P < 0.05). Conclusion: Faster LV untwisting plays a pivotal role in the rapid early diastolic filling occasionally seen in young healthy individuals. In contrast, in DCM patients untwisting is severely delayed and this impairment to utilize suction may reduce LV filling. (Echocardiography 2010;27:269‐274)     

New,Simple Echocardiographic Indexes for the Estimation of Filling Pressure in Patients with Cardiac Disease and Preserved Left Ventricular Ejection Fraction

Background: There are few data on echocardiographic indexes incorporating peak mitral inflow velocity (E), left atrial volume index (LAVi), and pulmonary artery pressure (PAP) for estimation of left ventricular (LV) filling pressure in patients with preserved LV ejection fraction (EF ≥ 50%). Methods: Patients underwent echocardiography ≤20 minutes of cardiac catheterization. Echocardiographic variables were compared to invasively measured LV end‐diastolic pressure (LVEDP). Results: Of the 122 patients, 67 (55%) were women, the mean age was 55 ± 9 years, the mean left ventricular ejection fraction (LVEF) was 61 ± 6%, 107 (88%) were hypertensive, and 79 (65%) had significant coronary artery disease at catheterization. E/Ea correlated with LVEDP (R = 0.68, P < 0.0001), compared to PAP (R = 0.53, P < 0.001), peak E velocity (R = 0.48, P < 0.001), and LAVi (R = 0.48, P < 0.001). E/Ea > 12 had 75% sensitivity and 78% specificity for LVEDP ≥ 20 mmHg (area under curve (AUC) = 0.79, P < 0.0001), compared with (PAP + LAVi)/2 > 30 (sensitivity = 72%, specificity = 80%, AUC = 0.84, P < 0.001) and (E + LAVi)/2 > 57 (sensitivity = 73% and specificity = 81%, AUC = 0.82, P < 0.001) (P = NS). E <60 cm/sec had 94% negative, and E>90 cm/sec had 96% positive, predictive value for LVEDP ≥ 20 mmHg. (E + LAVi)/2 added incrementally to E/Ea when E/Ea was in the gray zone. Conclusions: New, simple echocardiographic equations, (E + LAVi)/2 and (PAP + LAVi)/2, have comparable accuracy to E/Ea for LVEDP estimation in patients with cardiac disease and preserved LVEF, and (E + LAVi)/2 added incrementally to E/Ea alone when E/Ea was in the gray zone. Peak E velocity alone had high negative and positive predictive value for elevated LVEDP in this population. These simple echocardiographic variables could be used—in isolation or with E/Ea—in patients with cardiac disease and preserved LVEF for the diagnosis of diastolic heart failure. Echocardiography 2010;27:946‐953)     

Obesity as a risk factor for sustained ventricular tachyarrhythmias in MADIT II patients

Background: Obesity, as defined by body mass index ≥30 kg/m², has been shown to be a risk factor for cardiovascular disease. However, data on the relationship between body mass index (BMI) and the risk of ventricular arrhythmias and sudden cardiac death are limited. The aim of this study was to evaluate the risk of ventricular tachyarrhythmias and sudden death by BMI in patients after myocardial infarction with severe left ventricular dysfunction.
Methods : The risk of appropriate defibrillator therapy for ventricular tachycardia or ventricular fibrillation (VT/VF) by BMI status was analyzed in 476 nondiabetic patients with left ventricular dysfunction who received an implantable cardioverter defibrillator (ICD) in the Multicenter Automatic Defibrillator Implantation Trial-II (MADIT II).
Results : Mean BMI was 27 ± 5 kg/m². Obese patients comprised 25% of the study population. After 2 years of follow-up, the cumulative rates of appropriate ICD therapy for VT/VF were 39% in obese and 24% in nonobese patients, respectively (P = 0.014). In multivariate analysis, there was a significant 64% increase in the risk for appropriate ICD therapy among obese patients as compared with nonobese patients, which was attributed mainly to an 86% increase in the risk of appropriate ICD shocks (P = 0.006). Consistent with these results, the risk of the combined endpoint of appropriate VT/VF therapy or sudden cardiac death (SCD) was also significantly increased among obese patients (Hazard Ratio 1.59; P = 0.01).
Conclusions : Our findings suggest that in nondiabetic patients with ischemic left ventricular dysfunction, a BMI ≥30 kg/m² is an independent risk factor for ventricular tachyarrhythmias.     

Left ventricular inflow normal or pseudonormal. A new echocardiographic method: diastolic change of left atrial diameter

Mitral flow Doppler study has been used to evaluate left ventricle (LV) diastolic function. Through its use, greater A wave than E wave, pseudonormal pattern, and restrictive pattern were observed progressively in patients with more LV diastolic dysfunction. Differentiation of normal or pseudonormal mitral flow is very important. In this study, left atrium (LA) diameter change during diastole was used as a new method for the differentiation of normal and pseudonormal mitral flow. METHOD: Sixty-eight patients (30 men, 38 women; mean age 53 +/- 13 years) with echocardiographically determined diastolic dysfunction and 60 healthy volunteers (36 men, 24 women; mean age 49 +/- 12 years) were included in the study. Mitral flow E/A ratio, isovolumetric relaxation time (IVRT), and deceleration time (DT) of E wave were used for determination of the diastolic dysfunction. Thirty of 68 diastolic dysfunction patients had A>E wave, 20 had pseudonormal mitral flow pattern, and 18 had restrictive mitral flow pattern. Left parasternal long-axis echocardiographic window was used for the measurement of LA diameter. Left atrium emptying fraction (LAEF) was defined as ratio of end-diastolic LA diameter to end-systolic diameter. RESULTS: LAEF was found 0.69 +/- 0.01 (mean +/- SE) in the control group, 0.76 +/- 0.01 in the A>E group (P < 0.05, control vs A > E group), 0.83 +/- 0. 05 in the pseudonormal pattern group (P < 0.05, control vs pseudonormal pattern group), and 0.87 +/- 0.01 in the restrictive pattern group (P < 0.001, control vs restrictive pattern group). CONCLUSION: (1) LV diastolic dysfunction reduces the filling of LA content to the LV during diastole; (2) LA diameter changes during diastole as a new and practical method for the differentiation of the normal-pseudonormal mitral flow pattern.     

TISSUE CHARACTERIZATION TO DIFFERENTIATE PATHOLOGICAL FROM PHYSIOLOGICAL HYPERTROPHY IN PATIENTS WITH HYPERTENSION AND ATHLETES

Precedents: In pathological left ventricular (LV) hypertrophy (H) of hypertensive patients (P) there is a deposition of collagen. Myocardial fibrosis is one of the factors responsible for systolic and diastolic dysfunction. Athletes increase their ventricular mass as physiological ventricular H. Integrated backscatter (IB) demonstrates changes in myocardial acoustic properties, depending upon their composition and function.
Objectives: (1).Assess the capability of IB to differentiate physiological from pathological H. (2).Correlate IB with overall and regional systolic and diastolic functions.
Methods: Group I(GI):13 hypertensive P with an LV mass index (LVMI)>124 gr/m², Group II(G2):11 athletes, Group III(G3): 8 volunteers. We determined overall systolic and diastolic functions and regional function of the basal septum, IB and cyclic variation of the IB (CVIB) of the posterior wall.
Results: Age (years): G1:52 ± 15, G2:28 ± 8 G3:35 ± 8 p = 0.000; Sex: G1:m/f 12/1, G2: m/f 9/2, G3: m/f 4/4, LVMI: G1: 180.1 ± 58 gr/m², G2:130.2 ± 20 gr/m² G3: 90.2 ± 16 gr/m² p = 0.000. Left atrial area (LAA): G1: 22 ± 4 cm², G2: 18.8 ± 1.8 cm², G3: 15.8 cm² p = 0.001, mid-wall shortening fraction (MWSF): G1:26.9 ± 3.5, G2:27.5 ± 4 G3:25 ± 3 p = NS; CVIB: G1:5,3 ± 2,5 G2:7.6 ± 2,1 G3:6.4 ± 1.1 P = 0.048.Correlation of IB and MWSF, p = NS; IB and MWSF p = NS, IB and CVIB:-0.56 p = 0.005.  

  TABLE     

11.

Effects of left ventricular systolic dysfunction on left atrial appendage and left atrial functions in patients with chronic nonvalvular atrial fibrillation   总被引：1，自引：0，他引：1  

Cemri M  Timurkaynak T  Ozdemir M  Boyaci B  Yalcin R  Cengel A  Dörtlemez O  Dörtlemez H 《Acta cardiologica》2002,57(2):101-105

OBJECTIVE: It has been claimed that left ventricular (LV) systolic dysfunction impairs left atrial (LA) and left atrial appendage (LAA) functions. In this study, we compared the LA and LAA function parameters in patients with chronic nonvalvular atrial fibrillation (AF) with and without LV systolic dysfunction. METHODS AND RESULTS: The study population consisted of 28 patients with chronic nonvalvularAF. Group I consisted of 12 patients with LV systolic dysfunction (mean age: 61 +/- 14 years; LV ejection fraction: 44 +/- 6%), group II of 16 patients with normal LV systolic function (mean age: 52 +/- 15 years; LV ejection fraction: 65 +/- 3%). LV ejection fraction (EF) was measured by echocardiography utilizing bi-plane area length method.The following LA and LAA transoesophageal echocardiography parameters were obtained: I) LA diameter, 2) LAA ejection velocity, 3) LAA filling velocity, 4) LAA ejection fraction, 5) pulmonary venous (PV) systolic velocity, 6) PV diastolic velocity, 7) PV systolic velocity/diastolic velocity ratio.The left atrium diameter was significantly larger in group I than in group 11 (4.7 +/- 0.7 cm vs. 3.8 +/- 0.6 cm, p < 0.05).The LAA ejection velocity and LAA ejection fraction were significantly lower in group I than in group 11 (22.6 +/- 15.5 cm/s vs 37.5 +/- 11.3 cm/s and 26.9 +/- 20.8% vs. 41.3 +/- 10.9%, p < 0.05 for both comparisons).The PV systolic velocity and PV systolic velocity/diastolic velocity ratio were significantly smaller in group I than in group II (26.2 +/- 14.8 cm/s vs. 51.5 +/- 22 cm/s and 0.7 +/- 0.6 vs. 1.2 +/- 0.5, p < 0.05 for both comparisons).Although decreased LAA filling and PV diastolic velocities were determined in group I, no significant difference existed between groups I and II.Thrombus and/or spontaneous echo contrast (SEC) in the LA and/or LAA were more frequent in group I (75% vs. 18%, p < 0.05). CONCLUSION: These results indicate that LV systolic dysfunction impairs various LA and LA function parameters and is associated with an increased frequency of SEC and/or LA thrombus in patients with chronic nonvalvularAF.     

12.

Relation between left ventricular mass indexes and cardiac function in hypertensive patients: an approach with Doppler echocardiography]     

T P Wang  X J Liu 《中华内科杂志》1992,31(9):543-5, 586

73 age-matched hypertensive patients, 46 men and 27 women, were divided into the four groups according to left ventricular mass indexes (LVMI) and normal control groups were established correspondingly. Doppler and M-mode echocardiography were used to assess the systolic and diastolic functions of left ventricle (LV) and the alterations of heart construction. It was shown that when the LVMI increased slightly, the internal dimension and systolic function of LV had no significant change, but the diastolic function became abnormal and the left atrium enlarged. When the LVMI increased significantly, both the left atrium and left ventricle enlarged and the systolic and diastolic functions of LV were impaired. It is concluded that increase of LV mass may be present in the early stage of hypertension and left atrial enlargement is an early sign of left ventricular diastolic dysfunction, which occurs before systolic dysfunction in the patients with essential hypertension.     

13.

L wave in echo Doppler     

Vipin Kumar  John Jose  V. Jacob Jose 《Indian heart journal》2014,66(3):392-393

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.     

14.

Clinical evaluation of left ventricular diastolic performance   总被引：24，自引：1，他引：24  

William C. Little  Thomas R. Downes 《Progress in cardiovascular diseases》1990,32(4):273-290

Diastole can be divided into four phases: isovolumic relaxation, early filling, diastasis, and atrial systole. The amount of LV filling that occurs during each of these phases depends on myocardial relaxation, the passive characteristics of the LV, the characteristics of the left atrium, pulmonary veins, and mitral valve, and the heart rate. When diastolic function is normal, the net effect of these factors results in an LV filling sufficient to produce an adequate cardiac output, while mean pulmonary venous pressure is maintained below 12 mm Hg. In the absence of systolic dysfunction, abnormal diastolic performance is usually due to abnormal relaxation and/or changes in the passive LV characteristics. Invasive studies can quantitate the rate of myocardial relaxation and the LV diastolic pressure-volume relation. More recently, RNA and Doppler echocardiography have been used to noninvasively evaluate diastolic performance by determining the pattern of LV diastolic filling. At rest, most LV filling occurs early in diastole. Conditions that produce diastolic dysfunction, such as LV hypertrophy and ischemia, are associated with reduced early diastolic filling and an augmented importance of atrial systole. It is important to recognize that such patterns can occur in patients who do not have clinically apparent diastolic dysfunction and in normals. Furthermore, a normal pattern can occur in patients who have severe diastolic dysfunction. A reduced early diastolic filling, in the absence of pulmonary congestion, indicates the loss of diastolic reserve, since the left atrium is being used as a booster pump. This pattern of diastolic filling in a patient who has symptoms of pulmonary congestion may suggest diastolic dysfunction, even if the systolic LV performance is normal. Since diastolic filling of the LV results from a complex interplay of factors, it is unlikely that a single, easily interpreted index of LV diastolic performance will ever be developed. However, the recent development of a noninvasive evaluation of the pattern of LV diastolic filling by RNA or Doppler echocardiography is an important advance. When interpreted with an understanding of the determinants of LV filling and the patient's clinical status, these noninvasive tests can contribute to the rational assessment of LV diastolic performance.     

15.

Assessment of global and regional left ventricular diastolic function in hypertensive heart disease using automated border detection techniques   总被引：9，自引：0，他引：9  

Spencer KT  Lang RM  Kirkpatrick JN  Mor-Avi V 《Echocardiography (Mount Kisco, N.Y.)》2003,20(7):673-681

Acoustic quantification (AQ) and color kinesis (CK) are techniques that involve automated detection and tracking of endocardial borders. These methods are useful for the evaluation of global and regional left ventricular (LV) systolic function and more recently have been applied to evaluating LV diastolic performance. Assessment of diastolic dysfunction in hypertensive heart disease is a relevant clinical issue in which these techniques have proven useful. The diastolic portion of left atrium and LV AQ area waveforms are frequently abnormal in patients with left ventricular hypertrophy (LVH). Left ventricular AQ curves consistently demonstrate reduced rapid filling fraction (RFF) and peak rapid filling rate (PRFR), elevated atrial filling fraction (AFF), peak atrial filling rate (PAFR), and reductions in the ratio PRFR/PAFR. Acoustic quantification complements traditional Doppler echocardiographic evaluation of global diastolic function. Many patients with significant LVH and normal Doppler diastolic parameters can be identified as having diastolic dysfunction with AQ. In addition, CK has allowed the evaluation of regional diastolic performance in hypertensive patients. Regional filling curves obtained from CK have demonstrated that endocardial diastolic motion is commonly delayed and heterogeneous in patients with LVH.     

16.

N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and diastolic dysfunction of the left ventricle.     

Marcia M Barbosa  Maria do Carmo P Nunes  Ant?nio Luiz P Ribeiro  Marselha M Barral  Manoel Otávio C Rocha 《European journal of echocardiography》2007,8(3):204-212

AIMS: NT-proBNP levels are known to be elevated in systolic and diastolic dysfunction. Doppler indices of diastolic dysfunction (DD) have been shown to have prognostic value in patients with Chagas' cardiomyopathy (CC). However, the additional value of NT-proBNP levels in further stratifying these patients according to DD has not been established. This study analyzed the correlation of N-terminal proBNP (NT-proBNP) levels with systolic and diastolic function in patients with CC. METHODS AND RESULTS: NT-proBNP levels were measured in 59 patients with dilated cardiomyopathy due to Chagas disease without other systemic illness that were studied by Doppler echocardiography, including left atrial volume (LAV) calculation and tissue Doppler evaluation of LV longitudinal function. Univariate analysis showed a strong correlation of NT-proBNP values with LVEF (r=-0.733, p<0.001) and a weak correlation with most Doppler echocardiographic parameters of diastolic function. On a multivariate analysis, LVEF and LAV volume emerged as correlating with elevated levels of the NT-proBNP. Patients with restrictive filling pattern (n=10), when compared to other patterns of DD, (n=49), showed a lower LVEF (25.4+/-6.4% vs. 39.8+/-9.4, p<0.001), a larger LAV (50.1+/-17.2 vs. 37.7+/-15.6 ml/m(2), p=0.004) and higher NT-proBNP levels (median+/-IQR: 3488+/-3056 vs. 492+/-700 pg/dl, p<0.001). A marked elevated concentration of NT-proBNP (> or =800 pg/ml) had a sensitivity of 90.0%, specificity of 70.5%, positive predictive value of 40.9% and negative predictive value of 96.9% for detecting a restrictive filling pattern. CONCLUSION: In patients with CC, NT-proBNP augmentation is a marker of LV dysfunction, with higher levels correlating with the more severe forms of both systolic and diastolic dysfunction.     

17.

尿毒症维持性血液透析患者左心室构型和功能的超声心动图研究   总被引：3，自引：0，他引：3  

李爱莉  柯元南  曾玉杰  李文歌  卞维静 《中华心血管病杂志》2009,37(10)

目的 评价尿毒症维持性血液透析患者的左心室形态学及舒张、收缩功能.方法 入选尿毒症维持性血液透析患者40例(尿毒症组),正常人45例(对照组).应用常规超声心动图、组织多普勒、实时三维超声心动图的多项指标对比分析尿毒症组左心室形态学改变、左心室重构类型;分析左心窒舒张和收缩功能变化,并对舒张功能异常进行分级;评价左心窜收缩及舒张的同步性.结果 尿毒症组的室壁厚度、左心室质量指数、左心室质量/容积比值显著性高于对照组(P<0.01),左心室构型以向心型肥厚为主(占50.0%),其次为向心型重构和偏心型肥厚(各占17.5%).尿毒症组的各项舒张功能指标与对照组差异有统计学意义(P<0.05),舒张功能异常以松弛功能受损类型居多(占85.0%),其中38.2%伴有左心室充盈压升高.尿毒症组的左心室射血分数、每搏量与对照组差异无统计学意义,但组织多普勒二尖瓣环收缩期运动速度显著低于对照组(P<0.05).左心室收缩不同步指标两组差异无统计学意义,舒张不同步指标尿毒症组显著高于对照组(P<0.05).结论 左心室肥厚、心肌质量增加和左心室舒张功能异常是尿毒症维持性血透患者心肌损害最突出的特征,舒张功能异常的出现早于收缩功能异常.     

18.

Impact of Baseline Renal Function on Outcomes of Renal Artery Stenting in Hypertensive Patients     

Gregory M. Singer  MD  ; Michael S. Remetz  MD  ; Jeptha P. Curtis  MD  ; John F. Setaro  MD 《Journal of clinical hypertension (Greenwich, Conn.)》2009,11(11):615-620

Renal artery stenting may improve blood pressure (BP) and renal function in resistant hypertension patients; however, benefit may differ depending on the degree of renal dysfunction. The authors analyzed 67 consecutive patients receiving stenting for obstructive renal artery disease between 2002 and 2005. Patients were categorized as normal or mildly impaired according to estimated glomerular filtration rate (eGFR) (≥60 mL/min/1.73 m²), moderately impaired (eGFR 30 to 59 mL/min/1.73 m²), and severely impaired (eGFR <30 mL/min/1.73 m²). In patients with eGFR ≥60, systolic BP did not significantly improve from baseline. However, in patients with an eGFR between 30 and 59 mL/min/1.73 m², systolic BP decreased by 12 mm Hg at 6 months (P=.02) and 14 mm Hg at 12 months (P=.01). Greater benefit was observed in patients with eGFR <30 mL/min/1.73 m², with a 16 mm Hg (P=.10) and 21 mm Hg (P=.02) decrease at 6 and 12 months, respectively. Renal function was stable across all groups. Renal artery stenting reduced BP and produced greatest benefit in patients with baseline impaired renal function.     

19.

Upgrading Pacemaker Patients with Right Ventricular Apical Pacing to Right Ventricular Septal Pacing Improves Left Ventricular Performance and Functional Capacity   总被引：1，自引：0，他引：1  

HUNG-FAT TSE  M.D.  Ph.D.  †  KWONG-KUEN WONG  M.B.B.S.  ‡  CHUNG-WAH SIU  M.B.B.S.  †  XUE-HUA ZHANG  M.D.  Ph.D.  WAI-YIN HO  M.B.B.S.  ‡  CHU-PAK LAU  M.D. 《Journal of cardiovascular electrophysiology》2009,20(8):901-905

Background : Right ventricular (RV) apical pacing results in abnormal left ventricular (LV) electrical and mechanical activation and is associated with an increased risk of developing heart failure. Chronic RV septal pacing has been shown to be superior to RV apical pacing in newly implanted patients. However, whether RV septal pacing can reverse deleterious effects of RV apical pacing remain unclear.
Methods : We evaluated the effects of RV septal pacing on LV performance and functional capacity before and at 18 months after device replacement in 12 patients with previously permanent RV apical pacing and in 12 control patients that continued RV apical pacing. All patients underwent radionuclide ventriculography and 6-minute hallwalk (6-MHW) test before replacement (baseline) and at 18 months afterward to determine changes in LV performance and functional capacity, respectively.
Results : After RV septal upgraded, there was a significant decrease in paced QRS duration (171.2 ± 3.9 ms to 160.4 ± 3.5 ms, P = 0.0016), increase in LV ejection fraction (55.2 ± 2.6% vs 60.4 ± 2.9%, P = 0.0002), the peak ventricular filling rate (2.60 ± 0.13 s⁻¹ vs 3.01 ± 0.14 s⁻¹, P = 0.046), and 6-MHW (308.2 ± 31.6 m vs 355.5 ± 34.2 m, P = 0.015) at 18 months compared with baseline. No changes in these parameters were observed in the control group (P > 0.05).
Conclusion : RV septal pacing upgraded improves LV systolic and diastolic function and functional capacity in patients with previously permanent RV apical pacing. These findings suggest that RV septal pacing can reverse the deleterious effects of RV apical pacing in patients who required permanent ventricular pacing.     

20.

Assessment of left ventricular diastolic function by three-dimensional transthoracic echocardiography     

Luigi P. Badano MD  PhD  Denisa Muraru MD  PhD  Francesca Ciambellotti MD  Sergio Caravita MD  PhD  Valentina Guida MD  Michele Tomaselli MD  Gianfranco Parati MD 《Echocardiography (Mount Kisco, N.Y.)》2020,37(11):1951-1956

Doppler echocardiography assessment of left ventricular (LV) filling pressures at rest and during exercise is the most widely used imaging technique to assess LV diastolic function in clinical practice. However, a sizable number of patients evaluated for suspected LV diastolic function show an inconsistency between the various parameters included in the flowchart recommended by current Doppler echocardiography guidelines and results in an undetermined LV diastolic function. Current three-dimensional echocardiography technology allows obtaining accurate measurements of the left atrial volumes and functions that have been shown to improve the diagnostic accuracy and prognostic value of the algorithms recommended for assessing both LV diastolic dysfunction and heart failure with preserved ejection fraction. Moreover, current software packages used to quantify LV size and function provide also volume-time curves showing the dynamic LV volume change throughout the cardiac cycle. Examining the diastolic part of these curves allows the measurement of several indices of LV filling that have been reported to be useful to differentiate patients with normal LV diastolic function from patients with different degrees of diastolic dysfunction. Finally, several software packages allow to obtain also myocardial deformation parameters from the three-dimensional datasets of both the left atrium and the LV providing additional functional parameters that may be useful to improve the diagnostic yield of three-dimensional echocardiography for the LV diastolic dysfunction. This review summarizes the current applications of three-dimensional echocardiography to assess LV diastolic function.     

Effects of left ventricular systolic dysfunction on left atrial appendage and left atrial functions in patients with chronic nonvalvular atrial fibrillation

OBJECTIVE: It has been claimed that left ventricular (LV) systolic dysfunction impairs left atrial (LA) and left atrial appendage (LAA) functions. In this study, we compared the LA and LAA function parameters in patients with chronic nonvalvular atrial fibrillation (AF) with and without LV systolic dysfunction. METHODS AND RESULTS: The study population consisted of 28 patients with chronic nonvalvularAF. Group I consisted of 12 patients with LV systolic dysfunction (mean age: 61 +/- 14 years; LV ejection fraction: 44 +/- 6%), group II of 16 patients with normal LV systolic function (mean age: 52 +/- 15 years; LV ejection fraction: 65 +/- 3%). LV ejection fraction (EF) was measured by echocardiography utilizing bi-plane area length method.The following LA and LAA transoesophageal echocardiography parameters were obtained: I) LA diameter, 2) LAA ejection velocity, 3) LAA filling velocity, 4) LAA ejection fraction, 5) pulmonary venous (PV) systolic velocity, 6) PV diastolic velocity, 7) PV systolic velocity/diastolic velocity ratio.The left atrium diameter was significantly larger in group I than in group 11 (4.7 +/- 0.7 cm vs. 3.8 +/- 0.6 cm, p < 0.05).The LAA ejection velocity and LAA ejection fraction were significantly lower in group I than in group 11 (22.6 +/- 15.5 cm/s vs 37.5 +/- 11.3 cm/s and 26.9 +/- 20.8% vs. 41.3 +/- 10.9%, p < 0.05 for both comparisons).The PV systolic velocity and PV systolic velocity/diastolic velocity ratio were significantly smaller in group I than in group II (26.2 +/- 14.8 cm/s vs. 51.5 +/- 22 cm/s and 0.7 +/- 0.6 vs. 1.2 +/- 0.5, p < 0.05 for both comparisons).Although decreased LAA filling and PV diastolic velocities were determined in group I, no significant difference existed between groups I and II.Thrombus and/or spontaneous echo contrast (SEC) in the LA and/or LAA were more frequent in group I (75% vs. 18%, p < 0.05). CONCLUSION: These results indicate that LV systolic dysfunction impairs various LA and LA function parameters and is associated with an increased frequency of SEC and/or LA thrombus in patients with chronic nonvalvularAF.     

Relation between left ventricular mass indexes and cardiac function in hypertensive patients: an approach with Doppler echocardiography]

73 age-matched hypertensive patients, 46 men and 27 women, were divided into the four groups according to left ventricular mass indexes (LVMI) and normal control groups were established correspondingly. Doppler and M-mode echocardiography were used to assess the systolic and diastolic functions of left ventricle (LV) and the alterations of heart construction. It was shown that when the LVMI increased slightly, the internal dimension and systolic function of LV had no significant change, but the diastolic function became abnormal and the left atrium enlarged. When the LVMI increased significantly, both the left atrium and left ventricle enlarged and the systolic and diastolic functions of LV were impaired. It is concluded that increase of LV mass may be present in the early stage of hypertension and left atrial enlargement is an early sign of left ventricular diastolic dysfunction, which occurs before systolic dysfunction in the patients with essential hypertension.     

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.     

Clinical evaluation of left ventricular diastolic performance

Diastole can be divided into four phases: isovolumic relaxation, early filling, diastasis, and atrial systole. The amount of LV filling that occurs during each of these phases depends on myocardial relaxation, the passive characteristics of the LV, the characteristics of the left atrium, pulmonary veins, and mitral valve, and the heart rate. When diastolic function is normal, the net effect of these factors results in an LV filling sufficient to produce an adequate cardiac output, while mean pulmonary venous pressure is maintained below 12 mm Hg. In the absence of systolic dysfunction, abnormal diastolic performance is usually due to abnormal relaxation and/or changes in the passive LV characteristics. Invasive studies can quantitate the rate of myocardial relaxation and the LV diastolic pressure-volume relation. More recently, RNA and Doppler echocardiography have been used to noninvasively evaluate diastolic performance by determining the pattern of LV diastolic filling. At rest, most LV filling occurs early in diastole. Conditions that produce diastolic dysfunction, such as LV hypertrophy and ischemia, are associated with reduced early diastolic filling and an augmented importance of atrial systole. It is important to recognize that such patterns can occur in patients who do not have clinically apparent diastolic dysfunction and in normals. Furthermore, a normal pattern can occur in patients who have severe diastolic dysfunction. A reduced early diastolic filling, in the absence of pulmonary congestion, indicates the loss of diastolic reserve, since the left atrium is being used as a booster pump. This pattern of diastolic filling in a patient who has symptoms of pulmonary congestion may suggest diastolic dysfunction, even if the systolic LV performance is normal. Since diastolic filling of the LV results from a complex interplay of factors, it is unlikely that a single, easily interpreted index of LV diastolic performance will ever be developed. However, the recent development of a noninvasive evaluation of the pattern of LV diastolic filling by RNA or Doppler echocardiography is an important advance. When interpreted with an understanding of the determinants of LV filling and the patient's clinical status, these noninvasive tests can contribute to the rational assessment of LV diastolic performance.     

Assessment of global and regional left ventricular diastolic function in hypertensive heart disease using automated border detection techniques

Acoustic quantification (AQ) and color kinesis (CK) are techniques that involve automated detection and tracking of endocardial borders. These methods are useful for the evaluation of global and regional left ventricular (LV) systolic function and more recently have been applied to evaluating LV diastolic performance. Assessment of diastolic dysfunction in hypertensive heart disease is a relevant clinical issue in which these techniques have proven useful. The diastolic portion of left atrium and LV AQ area waveforms are frequently abnormal in patients with left ventricular hypertrophy (LVH). Left ventricular AQ curves consistently demonstrate reduced rapid filling fraction (RFF) and peak rapid filling rate (PRFR), elevated atrial filling fraction (AFF), peak atrial filling rate (PAFR), and reductions in the ratio PRFR/PAFR. Acoustic quantification complements traditional Doppler echocardiographic evaluation of global diastolic function. Many patients with significant LVH and normal Doppler diastolic parameters can be identified as having diastolic dysfunction with AQ. In addition, CK has allowed the evaluation of regional diastolic performance in hypertensive patients. Regional filling curves obtained from CK have demonstrated that endocardial diastolic motion is commonly delayed and heterogeneous in patients with LVH.     

N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and diastolic dysfunction of the left ventricle.

AIMS: NT-proBNP levels are known to be elevated in systolic and diastolic dysfunction. Doppler indices of diastolic dysfunction (DD) have been shown to have prognostic value in patients with Chagas' cardiomyopathy (CC). However, the additional value of NT-proBNP levels in further stratifying these patients according to DD has not been established. This study analyzed the correlation of N-terminal proBNP (NT-proBNP) levels with systolic and diastolic function in patients with CC. METHODS AND RESULTS: NT-proBNP levels were measured in 59 patients with dilated cardiomyopathy due to Chagas disease without other systemic illness that were studied by Doppler echocardiography, including left atrial volume (LAV) calculation and tissue Doppler evaluation of LV longitudinal function. Univariate analysis showed a strong correlation of NT-proBNP values with LVEF (r=-0.733, p<0.001) and a weak correlation with most Doppler echocardiographic parameters of diastolic function. On a multivariate analysis, LVEF and LAV volume emerged as correlating with elevated levels of the NT-proBNP. Patients with restrictive filling pattern (n=10), when compared to other patterns of DD, (n=49), showed a lower LVEF (25.4+/-6.4% vs. 39.8+/-9.4, p<0.001), a larger LAV (50.1+/-17.2 vs. 37.7+/-15.6 ml/m(2), p=0.004) and higher NT-proBNP levels (median+/-IQR: 3488+/-3056 vs. 492+/-700 pg/dl, p<0.001). A marked elevated concentration of NT-proBNP (> or =800 pg/ml) had a sensitivity of 90.0%, specificity of 70.5%, positive predictive value of 40.9% and negative predictive value of 96.9% for detecting a restrictive filling pattern. CONCLUSION: In patients with CC, NT-proBNP augmentation is a marker of LV dysfunction, with higher levels correlating with the more severe forms of both systolic and diastolic dysfunction.     

尿毒症维持性血液透析患者左心室构型和功能的超声心动图研究

目的 评价尿毒症维持性血液透析患者的左心室形态学及舒张、收缩功能.方法 入选尿毒症维持性血液透析患者40例(尿毒症组),正常人45例(对照组).应用常规超声心动图、组织多普勒、实时三维超声心动图的多项指标对比分析尿毒症组左心室形态学改变、左心室重构类型;分析左心窒舒张和收缩功能变化,并对舒张功能异常进行分级;评价左心窜收缩及舒张的同步性.结果 尿毒症组的室壁厚度、左心室质量指数、左心室质量/容积比值显著性高于对照组(P<0.01),左心室构型以向心型肥厚为主(占50.0%),其次为向心型重构和偏心型肥厚(各占17.5%).尿毒症组的各项舒张功能指标与对照组差异有统计学意义(P<0.05),舒张功能异常以松弛功能受损类型居多(占85.0%),其中38.2%伴有左心室充盈压升高.尿毒症组的左心室射血分数、每搏量与对照组差异无统计学意义,但组织多普勒二尖瓣环收缩期运动速度显著低于对照组(P<0.05).左心室收缩不同步指标两组差异无统计学意义,舒张不同步指标尿毒症组显著高于对照组(P<0.05).结论 左心室肥厚、心肌质量增加和左心室舒张功能异常是尿毒症维持性血透患者心肌损害最突出的特征,舒张功能异常的出现早于收缩功能异常.     

Impact of Baseline Renal Function on Outcomes of Renal Artery Stenting in Hypertensive Patients

Renal artery stenting may improve blood pressure (BP) and renal function in resistant hypertension patients; however, benefit may differ depending on the degree of renal dysfunction. The authors analyzed 67 consecutive patients receiving stenting for obstructive renal artery disease between 2002 and 2005. Patients were categorized as normal or mildly impaired according to estimated glomerular filtration rate (eGFR) (≥60 mL/min/1.73 m²), moderately impaired (eGFR 30 to 59 mL/min/1.73 m²), and severely impaired (eGFR <30 mL/min/1.73 m²). In patients with eGFR ≥60, systolic BP did not significantly improve from baseline. However, in patients with an eGFR between 30 and 59 mL/min/1.73 m², systolic BP decreased by 12 mm Hg at 6 months (P=.02) and 14 mm Hg at 12 months (P=.01). Greater benefit was observed in patients with eGFR <30 mL/min/1.73 m², with a 16 mm Hg (P=.10) and 21 mm Hg (P=.02) decrease at 6 and 12 months, respectively. Renal function was stable across all groups. Renal artery stenting reduced BP and produced greatest benefit in patients with baseline impaired renal function.     

Upgrading Pacemaker Patients with Right Ventricular Apical Pacing to Right Ventricular Septal Pacing Improves Left Ventricular Performance and Functional Capacity

Background : Right ventricular (RV) apical pacing results in abnormal left ventricular (LV) electrical and mechanical activation and is associated with an increased risk of developing heart failure. Chronic RV septal pacing has been shown to be superior to RV apical pacing in newly implanted patients. However, whether RV septal pacing can reverse deleterious effects of RV apical pacing remain unclear.
Methods : We evaluated the effects of RV septal pacing on LV performance and functional capacity before and at 18 months after device replacement in 12 patients with previously permanent RV apical pacing and in 12 control patients that continued RV apical pacing. All patients underwent radionuclide ventriculography and 6-minute hallwalk (6-MHW) test before replacement (baseline) and at 18 months afterward to determine changes in LV performance and functional capacity, respectively.
Results : After RV septal upgraded, there was a significant decrease in paced QRS duration (171.2 ± 3.9 ms to 160.4 ± 3.5 ms, P = 0.0016), increase in LV ejection fraction (55.2 ± 2.6% vs 60.4 ± 2.9%, P = 0.0002), the peak ventricular filling rate (2.60 ± 0.13 s⁻¹ vs 3.01 ± 0.14 s⁻¹, P = 0.046), and 6-MHW (308.2 ± 31.6 m vs 355.5 ± 34.2 m, P = 0.015) at 18 months compared with baseline. No changes in these parameters were observed in the control group (P > 0.05).
Conclusion : RV septal pacing upgraded improves LV systolic and diastolic function and functional capacity in patients with previously permanent RV apical pacing. These findings suggest that RV septal pacing can reverse the deleterious effects of RV apical pacing in patients who required permanent ventricular pacing.     

Assessment of left ventricular diastolic function by three-dimensional transthoracic echocardiography

Doppler echocardiography assessment of left ventricular (LV) filling pressures at rest and during exercise is the most widely used imaging technique to assess LV diastolic function in clinical practice. However, a sizable number of patients evaluated for suspected LV diastolic function show an inconsistency between the various parameters included in the flowchart recommended by current Doppler echocardiography guidelines and results in an undetermined LV diastolic function. Current three-dimensional echocardiography technology allows obtaining accurate measurements of the left atrial volumes and functions that have been shown to improve the diagnostic accuracy and prognostic value of the algorithms recommended for assessing both LV diastolic dysfunction and heart failure with preserved ejection fraction. Moreover, current software packages used to quantify LV size and function provide also volume-time curves showing the dynamic LV volume change throughout the cardiac cycle. Examining the diastolic part of these curves allows the measurement of several indices of LV filling that have been reported to be useful to differentiate patients with normal LV diastolic function from patients with different degrees of diastolic dysfunction. Finally, several software packages allow to obtain also myocardial deformation parameters from the three-dimensional datasets of both the left atrium and the LV providing additional functional parameters that may be useful to improve the diagnostic yield of three-dimensional echocardiography for the LV diastolic dysfunction. This review summarizes the current applications of three-dimensional echocardiography to assess LV diastolic function.