Left ventricular diastolic function in hypertensive heart diseases. Comparison of results obtained by echocardiography and mechanocardiography

Usefulness of computerized mechanocardiography and echocardiography in the bedside diagnosis of impaired left ventricular diastolic function is established in a study comparing 17 hypertensive cardiomyopathy patients and 17 hypertrophic obstructive patients to 20 control. The echocardiographic study involves the ratio A/E obtained from the diastolic motion of the mitral valve and max DD/dtN, the peak rate of maximal diastolic dimension change. Both measurements allow statistical differentiation between pathological conditions and the control. The mechanocardiographic evaluation of left ventricular diastolic function provides easily three different parameters of diastolic function: isovolumic relaxation by the interval B2 alpha-0 or by t-dr/dt and the ratio dr/dt/A2, left ventricular stiffness by the A/H ratio and TRR the time of rapid filling. The mechanocardiographic indices allow clear distinction between the control group and the hypertrophic conditions for all the measured parameters giving evidence for an increased isovolumic relaxation period with a reduced velocity of relaxation, an increase in left ventricular stiffness and in the case of the hypertrophic obstructive cardiomyopathy, a prolonged time of rapid filling.     

Doppler echocardiographic evaluation of right ventricular diastolic function in hypertrophic cardiomyopathy.

AIMS: Left ventricular diastolic function in patients with hypertrophic cardiomyopathy has been adequately studied. In contrast there are few studies concerning right ventricular diastolic function in hypertrophic cardiomyopathy. We studied right ventricular diastolic function in patients with hypertrophic cardiomyopathy using Doppler echocardiography. METHODS AND RESULTS: We studied 20 patients with hypertrophic cardiomyopathy (mean age 43.6+/-13.8 years) and 20 healthy volunteers (control group, mean age 43+/-13.8 years). We calculated left ventricular and right ventricular diastolic indices using pulsed Doppler echocardiography. Hypertrophic cardiomyopathy patients compared with controls had significantly lower right ventricular-E/A ratio (1.01+/-0.40 vs 1.30+/-0.28, P<0.04), significantly prolonged right ventricular isovolumic relaxation time (170+/-72 vs 32+/-23 ms, P<0.001), and also significantly prolonged right ventricular deceleration time (160+/-58 vs 118+/-35 ms, P<0.01). There was also strong significant correlation between right ventricular deceleration time and left ventricular deceleration time (r=0.78), right ventricular-E/A ratio and left atrial filling fraction (r=-0.55) and between right atrial filling fraction and left atrial filling fraction (r=0.75). CONCLUSIONS: Right ventricular diastolic function in patients with hypertrophic cardiomyopathy is impaired, reflecting abnormal relaxation. Right ventricular diastolic indices correlate well with those of left ventricle.     

Left ventricular diastolic function in hypertrophic cardiomyopathy: assessment by radionuclide angiography

Diastolic left ventricular function was studied in 20 patients with obstructive hypertrophic cardiomyopathy, 10 with apical hypertrophic cardiomyopathy, and 20 control subjects. The left ventricular time-activity curve was filtered using Fourier expansion with 4 harmonics. The first and second derivatives of the filtered curve were used to define various parameters of the left ventricle. Isovolumic relaxation period and time to peak filling rate were prolonged in obstructive hypertrophic cardiomyopathy and apical hypertrophic cardiomyopathy (101.56 +/- 44.81 msec, 105.19 +/- 45.27 versus 72.19 +/- 29.36 (CS) P less than 0.05; 169.70 +/- 50.73 msec, 173.83 +/- 50.53 versus 138.02 +/- 29.54 (CS) P less than 0.05, respectively). Rapid filling period, diastasis, atrial contraction period, time to peak filling rate-isovolumic relaxation period, and filling fraction of diastasis were not significantly different in these groups. Fasting filling fraction was 11% lower in hypertrophic groups than in control subjects. The filling fraction of atrial contribution was 12% higher in hypertrophic groups. We conclude: Isovolumic relaxation period, rapid filling phase, and diastasis atrial contraction period can be clearly defined by this technique. Impaired relaxation is an important determinant of decreased left ventricular filling in patients with obstructive hypertrophic cardiomyopathy and apical hypertrophic cardiomyopathy. Prolonged time to peak filling rate is mainly due to increased isovolumic relaxation period in hypertrophic patients. Atrial contraction contributes to more stroke volume in patients with hypertrophic cardiomyopathy.     

Systolic and diastolic flow abnormalities in elderly patients with hypertensive hypertrophic cardiomyopathy

Seventeen patients with clinical and echocardiographic features of hypertensive hypertrophic cardiomyopathy of the elderly were studied to more completely characterize left ventricular systolic and diastolic function in this group. Measurements of left ventricular structure and systolic and diastolic function were made in the study patients and compared with those of age-matched control subjects. The study group had significantly greater left ventricular mass, wall thickness, shortening fraction and relative wall thickness than did the control subjects. Left ventricular end-diastolic dimension was smaller and left atrial size was not different in study patients compared with control subjects. Left ventricular filling was characterized by an increased peak atrial velocity and reduced ratio of peak early to peak atrial velocity in the study group. Left ventricular outflow velocities were elevated in 14 of the 17 study patients with peak velocities ranging from 1.2 to 5.0 m/s corresponding to a peak intraventricular gradient of 16 to 100 mm Hg. The velocity waveforms in these patients were late-peaking, similar to those described in hypertrophic obstructive cardiomyopathy. The elevated velocities were localized to the left ventricular outflow tract. These findings imply a pathophysiologic state in these elderly patients with long-standing hypertension, very similar to that in hypertrophic obstructive cardiomyopathy, and provide further support for the use of pharmacologic agents with negative inotropic properties or positive lusitropic properties in this group.     

Noninvasive assessment of left ventricular diastolic function by pulsed Doppler echocardiography in patients with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is a primary myocardial disease in which symptoms may frequently result from impaired left ventricular relaxation, filling and compliance. In the present investigation, Doppler echocardiography was utilized to measure transmitral flow velocity and thereby assess left ventricular diastolic performance noninvasively in a group of 111 patients representative of the broad clinical spectrum of hypertrophic cardiomyopathy. In patients with hypertrophic cardiomyopathy, all Doppler indexes of diastolic relaxation and filling differed significantly (p less than 0.001) from those obtained in 86 control subjects without heart disease, namely, prolongation of isovolumic relaxation (94 +/- 24 versus 78 +/- 12 ms) and of the early diastolic peak of flow velocity (244 +/- 55 versus 220 +/- 28 ms), as well as slower deceleration (3.4 +/- 1.4 versus 4.9 +/- 1.3 m/s2) and reduced maximal flow velocity in early diastole (0.5 +/- 0.2 versus 0.6 +/- 0.1 m/s). As an apparent compensation for impaired relaxation and early diastolic filling, the atrial contribution to left ventricular filling was increased, as shown by increased late diastolic flow velocity (0.4 +/- 0.3 versus 0.3 +/- 0.1 m/s) and reduced ratio of maximal flow velocity in early diastole to that in late diastole (1.4 +/- 0.8 versus 2.1 +/- 0.9). The vast majority of patients with hypertrophic cardiomyopathy (91 [82%] of 111) showed evidence of impaired left ventricular diastolic performance, as assessed from the Doppler waveform. Abnormal Doppler diastolic indexes were identified with similar frequency in patients with (78%) or without (83%) left ventricular outflow obstruction, as well as in patients with (84%) or without (80%) cardiac symptoms. However, patients with nonobstructive hypertrophic cardiomyopathy showed more severe alterations in the Doppler indexes of diastolic function than did patients with obstruction. Thus, abnormal diastolic performance as assessed by Doppler echocardiography was apparent in the vast majority of the study patients with hypertrophic cardiomyopathy, independent of the presence or absence of cardiac symptoms or a subaortic pressure gradient. The high frequency with which diastolic abnormalities are identified in asymptomatic patients with hypertrophic cardiomyopathy suggests that impaired diastolic performance may be present at a time in the natural history of the disease when functional limitation is not yet evident.     

Echocardiographic study on hypertrophic cardiomyopathy.

Echocardiographic study was performed on 21 cases with hypertrophic cardiomyopathy (HCM), 10 obstructive and 11 nonobstructive. Asymmetric septal hypertrophy was demonstrated in both obstructive and nonobstructive HCM. In all cases of HCM studied, the thickness of the interventricular septum was 1.4 cm or more (1.4-3.7 cm) and the ratio of septal to left ventricular posterior wall thickness was 1.4 or more (1.4-3.2). A systolic anterior movement of the mitral valve (SAM) was observed in obstructive cases only and characterized by a large backward component in late systole and an extreme approximation to the interventricular septum at its peak. Patients with HCM also showed abnormal echocardiographic indices of the left ventricular diastolic properties, such as the rate of diastolic descent of the mitral valve (DDR), mean diastolic posterior wall velocity (mPWVd), D/S ratio and mean rapid filling rate (mRFR). DDR correlated well with the ratio of rapid filling to total filling volume, rapid filling fraction, (r = 0.79, p less than 0.001), suggesting that reduced DDR in HCM was related with an abnormal left atrio-ventricular flow pattern. A significant correlation was also observed between mRFR and negative maximum dp/dt derived from the first derivative curve of the left ventricular pressure (r = o.68, p less than 0.005). Thus echocardiography was proved to be a valuable means for investigation of the left ventricular properties during early diastole.     

Contractile and relaxation reserve of the left ventricle. III. Patients with cardiomyopathy (author's transl)

Seven of 22 patients with cardiomyopathy increased maximal rate of left ventricular pressure rise (max dP/dt) above 3200 mm Hg/s and dP/dt/P above 60/s. Relaxation reserve was normal with an increase of min dP/dt above 2400 mm Hg/s.--In 15 patients contractile and relaxation reserve was reduced. In congestive cardiomyopathy, contractility and relaxation reserve were equally reduced. Left ventricular enddiastolic pressure increased during exercise slightly or not (grade 1). Enddiastolic volume was elevated to 173 +/- 50 ml/1.73 m2 and endsystolic volume to 63 +/- 22 ml/1.73 m2; ejection fraction and mean circumferential fiber shortening were reduced (61 +/- 17%; 1.3 +/- 0.9 circ/s). In hypertrophic cardiomyopathy without obstruction, contractile and relaxation reserve and ejection phase parameters could be found to be normal. Enddiastolic pressure at rest was elevated. In severe cases, contractile and relaxation reserve were markedly reduced and enddiastolic pressure increased to a greater extent than in congestive cardiomyopathy. In addition, relaxation reserve was reduced, especially in patients with excessive hypertrophy of the myocardium. These had abnormal (grade 2) and pathological reaction to exercise: contractile and relaxation reserve were decreased and enddiastolic pressure (grade 3) increased. Left ventricular contractility was found to be almost normal in patients with hypertrophic obstructive cardiomyopathy. This was the case despite increases in enddiastolic pressure. Contractile reserve was reduced, however, in patients with excessive hypertrophy. Diastolic filling was impeded during exercise.--Measuring left ventricular function during exercise, different types of cardiomyopathy correlate with typical hemodynamic alterations.     

Combined Doppler and M-mode analysis of diastolic filling behaviour in arterial hypertension with and without left ventricular hypertrophy

The authors analysed Doppler and M-mode derived diastolic parameters of left ventricular filling in patients with arterial hypertension with and without left ventricular hypertrophy (LVH) and with hypertrophic nonobstructive cardiomyopathy (HNCM). In hypertrophied hearts they demonstrated that the transmitral flow during rapid filling phase was significantly reduced. The lower early diastolic flow is compensated by an augmentation of atrial systole. Diastolic filling anomalies are the consequence of an impaired ventricular relaxation due to LVH as could been proved by the M-mode derived retraction constant Te. Diastolic filling anomalies significantly depend on the extent of left ventricular hypertrophy. Impaired diastolic function was found in hypertensive patients without LVH. In this case, diastolic disorders indicate an early involvement of the heart in the hypertensive process.     

Regional left ventricular asynchrony and impaired global left ventricular filling in hypertrophic cardiomyopathy: effect of verapamil

Left ventricular relaxation and filling are impaired in many patients with hypertrophic cardiomyopathy. To investigate the influence of regional heterogeneity on these global abnormalities, 48 patients with hypertrophic cardiomyopathy and sinus rhythm were studied by radionuclide angiography before and after 1 to 2 weeks of verapamil therapy (320 to 640 mg/day, median 480). Left ventricular regional function was assessed by subdividing the ventricular region of interest into 20 sectors and into four quadrants from which regional time-activity curves were derived. Diastolic asynchrony was measured as the regional variation in timing between minimal volume and peak filling rate, and heterogeneity in the magnitude of rapid diastolic filling was measured as the regional variation in percent contribution of atrial systole to end-diastolic volume. Compared with 28 normal subjects, the patients with hypertrophic cardiomyopathy had greater regional variation in both timing (35 +/- 24 versus 12 +/- 6 ms, p less than 0.001) and magnitude (10 +/- 6 versus 7 +/- 4%, p less than 0.02) of rapid filling. Verapamil reduced the regional variation in timing (to 21 +/- 16 ms, p less than 0.001) and magnitude (to 7 +/- 3%, p less than 0.001) of rapid filling. These regional changes, indicating more uniform regional diastolic performance after verapamil, were associated with improved global diastolic filling: global rapid filling increased in both rate and magnitude and time to peak filling rate decreased. These findings indicate that the beneficial effect of verapamil on left ventricular diastolic function in hypertrophic cardiomyopathy may be mediated by reduction in regional asynchrony.     

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)     

Relaxation in hypertrophic cardiomyopathy and hypertensive heart disease: relations between hypertrophy and diastolic function

AIM—To determine the relation between the extent and distribution of left ventricular hypertrophy and the degree of disturbance of regional relaxation and global left ventricular filling.
METHODS—Regional wall thickness (rWT) was measured in eight myocardial regions in 17 patients with hypertrophic cardiomyopathy, 12 patients with hypertensive heart disease, and 10 age matched normal subjects, and an asymmetry index calculated. Regional relaxation was assessed in these eight regions using regional isovolumetric relaxation time (rIVRT) and early to late peak filling velocity ratio (rE/A) derived from Doppler tissue imaging. Asynchrony of rIVRT was calculated. Doppler left ventricular filling indices were assessed using the isovolumetric relaxation time, the deceleration time of early diastolic filling (E-DT), and the E/A ratio.
RESULTS—There was a correlation between rWT and both rIVRT and rE/A in the two types of heart disease (hypertrophic cardiomyopathy: r = 0.47, p < 0.0001 for rIVRT; r = −0.20, p < 0.05 for rE/A; hypertensive heart disease: r = 0.21, p < 0.05 for rIVRT; r = −0.30, p = 0.003 for rE/A). The degree of left ventricular asymmetry was related to prolonged E-DT (r = 0.50, p = 0.001) and increased asynchrony (r = 0.42, p = 0.002) in all patients combined, but not within individual groups. Asynchrony itself was associated with decreased E/A (r = −0.39, p = 0.01) and protracted E-DT (r = 0.69, p < 0.0001) and isovolumetric relaxation time (r = 0.51, p = 0.001) in all patients. These correlations were still significant for E-DT in hypertrophic cardiomyopathy (r = 0.56, p = 0.02) and hypertensive heart disease (r = 0.59, p < 0.05) and for isovolumetric relaxation time in non-obstructive hypertrophic cardiomyopathy (n = 8, r = 0.87, p = 0.005).
CONCLUSIONS—Non-invasive ultrasonographic examination of the left ventricle shows that in both hypertrophic cardiomyopathy and hypertensive heart disease, the local extent of left ventricular hypertrophy is associated with regional left ventricular relaxation abnormalities. Asymmetrical distribution of left ventricular hypertrophy is indirectly related to global left ventricular early filling abnormalities through regional asynchrony of left ventricular relaxation.


Keywords: hypertrophic cardiomyopathy; hypertensive heart disease; isovolumetric relaxation; diastolic function     

Left ventricular diastolic function in hypertrophic cardiomyopathy

Impaired diastolic function of the hypertrophied and stiffened left ventricle is a characteristic feature of hypertrophic cardiomyopathy (Figure 1). Altered left ventricular filling dynamics and reduced left ventricular distensibility or increased left ventricular diastolic chamber stiffness are associated with reduced left ventricular stroke volume, increased left ventricular filling pressures and compressive effects on the coronary microcirculation. These factors contribute importantly to the clinical presentation of many patients, including symptoms of fatigue, dyspnea and angina pectoris. Reduced distensibility results both from factors determining the passive elastic properties of the ventricular chamber (including severity of hypertrophy, fibrosis and cellular disarray) and from factors influencing the rate and extent of active left ventricular relaxation (Figure 2). The factors contributing to impaired relaxation in hypertrophic cardiomyopathy are mediated via either inactivation dependent or load-dependent mechanisms. In laboratory animals, compromise of myocardial inactivation results in a persistent increase in intracellular calcium concentration and in prolonged interaction of the contractile proteins. Additionally, there is evidence for an increased number of active receptors for calcium antagonists and, lastly, for myocardial ischemia (Figure 3). Load-dependent mechanisms include diminished wall tension at the opening of the mitral valve, changes in afterload, contractility and coronary flow. Other factors are nonuniform and asynchronous regional ventricular function due to differing increases in thickness of the ventricular walls and ischemia (Figure 4). Calcium channel blockers exert a favorable influence on left ventricular relaxation and filling (Figure 5); verapamil and diltiazem are preferable to nifedipine. Verapamil increases left ventricular stroke volume without an increase in the end-diastolic pressure (Figure 6), reduces regional asynchrony if present, and leads to a more homogeneous regional diastolic filling (Figure 4).(ABSTRACT TRUNCATED AT 250 WORDS)     

Tissue Doppler imaging and long axis left ventricular function: hypertrophic cardiomyopathy versus athlete's heart.

BACKGROUND: The different diagnosis between hypertrophic cardiomyopathy and athlete's heart has important clinical implications. The assessment of long axis left ventricular function with tissue Doppler imaging in hypertrophic cardiomyopathy (showing systolic and diastolic dysfunction with heterogeneity and asynchrony), may be useful in the differentiation of these situations. AIM: To study, with tissue Doppler imaging, long axis left ventricular function in a population of athletes (rowers) and to compare it with a population of non-obstructive hypertrophic cardiomyopathy patients. METHODS: In 24 patients with non-obstructive hypertrophic cardiomyopathy and in 20 competitive rowers with similar age, blood pressure and heart rate, we analyzed mitral annulus motion with pulsed tissue Doppler imaging in the 4 sides of the annulus (septal, lateral, inferior, anterior), in apical views. In each wave (systolic, rapid filling and atrial contraction) we measured velocities, time intervals and velocity-time integrals, and calculated heterogeneity and asynchrony indices. Data were compared between the groups, between the different sides in each group ("parallel analysis") and with conventional indices of global function. RESULTS: Hypertrophic cardiomyopathy patients showed: systolic function: lower velocities and integrals, shorter ejection time and shorter systolic time. These abnormalities occurred even in annular sites contiguous to walls without hypertrophy. DIASTOLIC FUNCTION: Much lower rapid filling velocities and integrals, lower atrial contraction velocities and integrals, lower e/a, longer isovolumic relaxation time and time to peak rapid filling wave. These abnormalities occurred even in annular sites adjacent to walls without hypertrophy. In the athletes group, the e/a ratio was never < 1, in any annular site. In hypertrophic cardiomyopathy patients this ratio was < 1 in 27% of the sites. CONCLUSIONS: 1--Systolic and diastolic long axis left ventricular function is different in hypertrophic cardiomyopathy and in athletes, in all mitral annulus sides. 2--The presence of these abnormalities in annular sites contiguous to walls without hypertrophy suggests that this technique may be useful in the differential diagnosis between these groups, particularly in the "gray zone" of Maron.     

Influence of left ventricular diastolic function on vascular and humoral responses to head-up posture in hypertension

The left ventricular (LV) diastolic filling rate has been reported to be reduced in hypertensive patients. To investigate the possible influence of altered LV diastolic function in hypertension on peripheral vascular regulation, hemodynamic measurements were obtained in 16 hypertensive patients in the resting supine position and during head-up tilt. The study population included seven men and nine women with an age range of 30 to 62 years (mean, 49.5 years +/- 10.6). Measurements included LV peak filling rate (+dv/dt), LV peak ejection rate (-dv/dt), LV ejection fraction, heart rate, total peripheral resistance, stroke volume, and cardiac index. Moreover, we calculated the ratio relating left ventricular filling rate to left ventricular ejection rate (+dv/dt/-dv/dt) because a complex interaction between ventricular contraction and relaxation is well recognized. We observed that in patients with slow diastolic filling rate (ratio +dv/dt/-dv/dt less than 0.9), the increase in total peripheral resistance in response to head-up tilt was less marked than in those with normal LV filling rate (+dv/dt/-dv/dt greater than or equal to 0.9), whereas changes in stroke volume during tilt were not statistically different between the two groups. Conversely, supine resting cardiac index and total peripheral resistance was not significantly different among groups. We conclude that abnormal diastolic filling is associated with abnormal cardiovascular adjustment to changes in body posture. We suggest that the altered response to head-up posture is related to decreased sensitivity of low pressure receptors in the cardiopulmonary area as a result of impaired LV diastolic function.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left ventricular relaxation and filling pattern in different forms of left ventricular hypertrophy: An echocardiographic study

To study left ventricular relaxation and filling in different forms of left ventricular hypertrophy, echocardiograms of the left ventricle in 24 patients with hypertrophic obstructive cardiomyopathy and in 24 patients with chronic left ventricular pressure overload (due to aortic stenosis in 6 and to severe arterial hypertension in 18) were analyzed by computer and compared with those of 28 normal subjects. The relaxation time index (minimal left ventricular dimension to mitral valve opening) was 13 ± 15 ms in normal subjects. This index was prolonged in patients with cardiomyopathy (93 ± 37 ms) and overload (66 ± 31 ms). During the interval from minimal left ventricular dimension to mitral valve opening both groups with left ventricular hypertrophy showed a marked increase in left ventricular dimension of 4.0 ± 2.2 mm and 3.0 ±1.8 mm, respectively, which was significantly greater (p < 0.001) than in normal subjects (0.6 ± 0.5 mm). This was probably a result of an abnormal change in left ventricular shape during isovolumic relaxation.The rapid filling phase and the increase in dimension during this period were significantly reduced in hypertrophic obstructive cardiomyopathy and chronic pressure overload. In contrast to findings in the patients with cardiomyopathy, in those with pressure overload the reduced increase in left ventricular dimension during the rapid diastolic filling period was compensated for by a greater dimensional increase due to atrial contraction, resulting in a normal end-diastolic dimension. These data indicate that significant prolongation of isovolumic relaxation is seen in different forms of left ventricular hypertrophy and is often associated with an abnormal diastolic filling pattern.     

Relation between extent of left ventricular hypertrophy and diastolic filling abnormalities in hypertrophic cardiomyopathy

In hypertrophic cardiomyopathy, the relation between left ventricular diastolic impairment and magnitude of left ventricular hypertrophy has not been clearly defined. In the present study, Doppler echocardiographic indexes of left ventricular diastolic filling were compared in 78 patients with hypertrophic cardiomyopathy and in 72 normal control subjects of similar age, and the relation between abnormalities of diastolic filling and magnitude of left ventricular hypertrophy was assessed. In patients with hypertrophic cardiomyopathy, isovolumic relaxation was prolonged (94 +/- 25 ms); peak early diastolic flow velocity (53 +/- 18 cm/s), deceleration of flow velocity in early diastole (341 +/- 142 cm/s2) and the ratio between early and late peaks of flow velocity (1.6 +/- 0.9) were reduced; and peak late diastolic flow velocity was increased (38 +/- 15 cm/s) compared with values in control subjects (76 +/- 12 ms, 65 +/- 12 cm/s, 512 +/- 131 cm/s2, 2.3 +/- 0.8 and 30 +/- 7 cm/s, respectively; p less than 0.001). Individual patient analysis showed that diastolic filling was abnormal in 52 (67%) of the 78 patients with hypertrophic cardiomyopathy. However, within the patient group, none of the Doppler diastolic indexes showed a significant correlation with maximal left ventricular wall thickness or the wall thickness index (correlation coefficients ranged from -0.15 to 0.10).(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in the relaxation and compliance of the left ventricle in cardiomyopathy

In order to study the left ventricular diastolic events in cardiomyopathy, carotid pulse tracing, electrocardiogram, phonocardiogram and apexcardiogram with its first derivatives (dA/dt) were simultaneously recorded in 240 normal subjects, 30 patients with dilated cardiomyopathy (DCM) and 44 patients with hypertrophic cardiomyopathy (HCM). Total relaxation time (TRT), total relaxation time index (TRTI), the ratio of A wave to total diastolic amplitude in apexcardiogram (A/D), diastolic amplitude time index (DATI), the ratio of RF wave in apexcardiogram to the total amplitude of apex tracing (F/H) and the variables reflecting the diastolic properties were measured to evaluate the left ventricular relaxation and compliance. Meanwhile, two variables reflecting the contractile ability of the left ventricle were measured in order to compare with the diastolic events. The results demonstrated that in normal subjects relaxation and compliance of the left ventricle showed a tendency of natural "decay" with aging and in patients with DCM and HCM these were significantly decreased, especially in patients with HCM. A/D, which reflects the left ventricular compliance, was increased in patients with HCM as compared with normal subjects (P less than 0.01) and also with patients with DCM. It means that a greater A/D is in favor of the diagnosis of HCM rather than DCM. In addition to abnormal diastolic events, systolic dysfunction, as evidenced by remarkable abnormalities of the contractile variables (PEP/LVET and R-dA/dt.I), was found as well in patients with DCM.     

Tissue Doppler imaging in hypertrophic cardiomyopathy: impact of intraventricular obstruction on longitudinal left ventricular function.

BACKGROUND: In non-obstructive hypertrophic cardiomyopathy, tissue Doppler imaging of the mitral annulus shows severe systolic and diastolic dysfunction, with marked heterogeneity and asynchrony. In obstructive forms, the complexity of pathophysiological interactions makes conventional echocardiographic functional assessment extremely difficult and complex. OBJECTIVE: To study longitudinal left ventricular function with tissue Doppler imaging in the obstructive forms of hypertrophic cardiomyopathy. METHODS: Twenty-six patients with hypertrophic obstructive cardiomyopathy and 23 patients with the non-obstructive form of the disease, matched by age, were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data. RESULTS: In contrast to the non-obstructive forms, patients with intraventricular obstruction showed: Systolic function: similar velocities and integrals, the relations between the different sides of the annulus usually being preserved; longer isovolumic contraction time, time to peak s and PEP/LVET. Diastolic function: similar rapid filling and e/a velocities and integrals, lower atrial contraction velocity and integral, similar number of sides with e/a higher than or equal to 1 on the lateral and inferior side of the annulus; similar diastolic time intervals, except diastolic time. CONCLUSIONS: This study shows that the presence of dynamic intraventricular obstruction and the loading conditions of obstructive forms of hypertrophic cardiomyopathy do not significantly influence most annular tissue Doppler imaging parameters, showing the relative load independence of the technique. So, in obstructive hypertrophic cardiomyopathy patients: 1--Longitudinal systolic function (velocities) is similar to the non-obstructive forms--longitudinal systolic dysfunction. 2--Longitudinal diastolic function (velocities and time intervals) is similar to the non-obstructive forms--longitudinal diastolic dysfunction. 3--Left atrial dysfunction is more severe than in non-obstructive forms. 4--The inferior and lateral sides of the annulus should be those selected in order to identify pseudonormalization of the transmitral flow.     

Tissue Doppler imaging assessment of long axis left ventricular function in hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy is classically defined as a diastolic disease with normal systolic function. Long axis left ventricular function is an important and sensitive determinant of global ventricular function but its assessment is often difficult and complex. Tissue Doppler imaging of the mitral annulus allows the study of long axis left ventricular function. METHODS: 47 patients with non-obstructive hypertrophic cardiomyopathy and 45 healthy volunteers, matched by age and sex, were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony. Data were compared among the different sides in each group, between groups and with conventional Doppler data. RESULTS: In contrast to normal subjects, hypertrophic cardiomyopathy patients showed: 1--Systolic function: lower velocities, longer systolic time intervals (isovolumic relaxation time, time to peak s, ejection time), higher systolic asynchrony (time to peak s, ejection time, systolic time) and lower s/shortening fraction ratio. These changes occurred despite normal indices of global systolic function. 2--Diastolic function: lower velocities (much lower rapid filling velocity, lower atrial contraction velocity, lower septal e/a), higher e/a heterogeneity index, longer protodiastolic times (isovolumic relaxation time and time to peak e), higher diastolic asynchrony (time to peak e) and lower e wave integral. Hypertrophic cardiomyopathy patients also showed higher average number of annular sides with e/a < 1 per patient and higher percentage of e/a < 1, mainly on the septal side. CONCLUSIONS: This study shows that: 1--Tissue Doppler imaging allows the detailed analysis of long axis left ventricular function in hypertrophic cardiomyopathy patients. 2--Long axis systolic function is abnormal in this disease, even in the presence of normal indices of global systolic function. 3--Long axis diastolic function is deeply disturbed in hypertrophic cardiomyopathy, at ventricular and atrial levels. 4--Long axis dysfunction occurs in annular sides contiguous to hypertrophied and non-hypertrophied walls, highlighting the role of other factors in its pathophysiology.     

Effects of diltiazem on left ventricular diastolic behavior in patients with hypertrophic cardiomyopathy: evaluation with exercise pulsed Doppler echocardiography

To estimate the effects of diltiazem on the left ventricular diastolic abnormalities in patients with hypertrophic cardiomyopathy, transmitral flow velocity during diastole was studied before and immediately after dynamic leg exercise with the pulsed Doppler technique combined with two-dimensional echocardiography. Seventeen patients with hypertrophic cardiomyopathy and 24 apparently healthy men performed bicycle ergometer exercise in the supine position with the target heart rate set at 120 beats/min. The patients with cardiomyopathy were directed to perform the exercise at the same intensity after receiving 30 to 60 mg of diltiazem, three times daily, for 1 or 2 weeks. The pattern of transmitral flow velocity in diastole had two components, one corresponding to the rapid filling phase in early diastole and the other to the atrial contraction phase in late diastole. To assess left ventricular diastolic behavior, the following variables were analyzed: peak velocity in the rapid filling and atrial contraction phases, the ratio of peak velocity in the atrial contraction phase to that in the rapid filling phase, and pressure half-time. The changes in peak velocity in the atrial contraction phase, pressure half-time and the ratio of peak velocity in the atrial contraction phase to that in the rapid filling phase with exercise differed significantly between patients with hypertrophic cardiomyopathy with no medication and control subjects. After diltiazem, the response of these variables to exercise was almost identical in the two groups. These results suggest that diltiazem can lessen the left ventricular diastolic abnormality in patients with hypertrophic cardiomyopathy on dynamic exercise of mild intensity.