Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study

Comparative value of tissue Doppler imaging and m-mode color Doppler mitral flow propagation velocity for the evaluation of left ventricular filling pressure

BACKGROUND

Recently, two new indexes based on the ratio of transmitral early diastolic velocity (E) to tissue Doppler imaging (TDI), and early diastolic velocity of mitral annulus (E') and E to propagation velocity (Vp) have been proposed to predict left ventricular (LV) filling pressures. However, little is known about the comparative value of these two indexes.

METHODS

We studied 71 consecutive patients referred for coronary angiography (mean age +/- SD, 65 + 11 years; 21 patients with LV ejection fraction [EF] < 50%). Complete Doppler echocardiographic examination including TDI and Vp measurements and direct measurement of LV end-diastolic pressure (LVEDP) were performed simultaneously in the catheterization laboratory. LV filling pressures were considered elevated when LVEDP was > or = 15 mm Hg.

RESULTS

The correlation coefficients between E/E' and E/Vp and LVEDP were 0.68 (p = 0.01) and 0.54 (p = 0.01), respectively, in the overall population. The correlations were better in patients with low LV EF (< 50%) [0.8 (p = 0.01) and 0.77(p = 0.01)] and poor in patients with normal LV EF (0.57 [p = 0.05] and 0.41 [not significant]), respectively. Moreover, Vp measurements had higher interobserver variability compared to E' (14% vs 7%). The cutoff values for both indexes giving the best sensitivity and specificity in identifying LVEDP > or = 15 mm Hg were 9 for (E/E') and 2 for (E/Vp).

CONCLUSION

Both E/E' and E/Vp can be used for the evaluation of LV filling pressures. However, the sensitivity of these indexes, especially E/Vp, is hampered by EF. E/E' has a lower variability than Vp and should be preferred for estimation of filling pressures especially in patients with EF > 50%.

Tissue Doppler echocardiographic and color M-mode estimation of left atrial pressure in infants

OBJECTIVES

Using recorded flow and tissue Doppler, we evaluated the relation of peak velocity of early transmitral Doppler filling (E)/early diastolic velocity of the lateral mitral annulus (Ea) ratio and of E/flow propagation velocity (Vp) ratio to mean left atrial pressure in infants after surgery for congenital heart disease.

DESIGN

Experimental design.

SETTING

Pediatric intensive care unit.

PATIENTS

Thirty-seven infants aged 4 (3-8) months.

INTERVENTIONS

Patients underwent postoperative invasive hemodynamic monitoring with simultaneously obtained Doppler measurements.

MEASUREMENTS AND MAIN RESULTS

Values are expressed as median (25th-75th percentiles). Heart rate was 145 (135-157) beats/min. Left atrial pressure was 10 (8-12) mm Hg with E/Ea 16 (12-19) and E/Vp 1.9 (1.3-2.4). E/Ea and E/Vp ratios were higher in patients with left atrial pressure >10 mm Hg (n = 18), than in patients with left atrial pressure < or =10 mm Hg (n = 19) (E/Ea, 16 [15-25] vs. 12 [9-17], p = .01; E/Vp, 2.3 [1.9-2.8] vs. 1.4 [1-1.9]. respectively, p = .001). At a cutoff point of 15, E/Ea sensitivity for left atrial pressure >10 mm Hg was 17 of 18 (94%) with specificity 13 of 18 (72%). At a cutoff point of 2, E/Vp sensitivity for left atrial pressure >10 mm Hg was 15 of 18 (83%) with specificity 16 of 18 (89%). Areas under the receiver operating characteristic curves were 0.76 (E/Ea) and 0.83 (E/Vp).

CONCLUSIONS

Doppler ratios might be considered as promising noninvasive tools for left atrial pressure evaluation in infants after cardiac surgery.

Comparison of Different Methods for Detection of Diastolic Filling Abnormalities

OBJECTIVE

Heart failure is associated with poor prognosis and the differentiation of patients on the basis of diastolic filling patterns helps to identify several groups of patients with incrementally higher risk. However, this is reliant on accurate definition of filling patterns. The aim of this study was to compare preload reduction with contrast-enhanced pulmonary venous Doppler recordings for the correct assessment of diastolic filling pattern.

METHODS

In all, 20 patients with heart failure and 25 healthy volunteers were studied on 2 separate days. Preload reduction was achieved with the Valsalva maneuver (nonstandardized and standardized) and sublingual nitroglycerin. Responses were compared among the 3 methods and the filling patterns obtained on each day with the various methods compared.

RESULTS

Although pulmonary venous Doppler improved the diastolic classification over mitral Doppler, preload reduction resulted in better classification and improved sensitivity, specificity, and positive and negative predictive values. No advantage was observed for either the standardized Valsalva or pharmacologic preload reduction.

CONCLUSION

Preload reduction is an essential part of the assessment of diastolic filling grade in patients with heart failure as it can identify pseudonormal filling (mildly increased filling pressures), reversible restrictive filling (high filling pressures), and nonreversible restrictive filling pattern (very high filling pressures).

Feasibility of tissue magnetic resonance imaging: a pilot study in comparison with tissue Doppler imaging and invasive measurement

OBJECTIVES

This research was intended to determine the feasibility of tissue magnetic resonance (MR) imaging in comparison with tissue Doppler imaging and its potential implications for the estimation of filling pressure, in comparison with invasive measurement.

BACKGROUND

Evaluation of diastolic function using MR imaging is commonly confined to the study of transmitral flow. However, transmitral flow is unreliable for the estimation of left ventricular (LV) filling pressures in hypertrophy and normal systolic function. Normalizing early mitral velocity (E) for the influence of myocardial relaxation by combining E with early diastolic mitral septal tissue velocity (Ea) provides better Doppler estimates of filling pressures.

METHODS

Eighteen patients with hypertensive heart disease (LV mass index: 114 +/- 21 g/m(2)), absence of valvular regurgitation, and with normal or mildly reduced systolic function (LV ejection fraction: 57.6 +/- 6.5%) referred for cardiac catheterization, underwent consecutive measurement of mitral flow and septal tissue velocities with phase-contrast MR and Doppler. These data were compared with mean pulmonary capillary wedge pressure (PCWP).

RESULTS

There was a strong relation between MR (11.6 +/- 4.3) and Doppler-assessed (12.1 +/- 3.5) E/Ea (95% confidence interval of -1.5 to 0.5) (r = 0.89, p < 0.0001). In addition, E/Ea related strongly to invasively measured PCWP (MR: r = 0.80, p < 0.0001 and Doppler: r = 0.85, p < 0.0001).

CONCLUSIONS

Tissue MR imaging is a feasible method to assess Ea. Combining E and Ea allowed similar estimation of filling pressure by MR and Doppler, in good agreement with invasive measurement. The potential confounding effect of valvular regurgitation needs further study.

Ventricular hypertrophy increases NT-proBNP in subjects with and without hypertension

BACKGROUND

It has been published that hypertension (HT) must be taken into account when using NT-proBNP, but left ventricular (LV) hypertrophy without HT could be a cause of NT-proBNP elevation. In a population study we compared NT-proBNP in subjects with hypertrophy, with and without diagnosis of HT.

METHODS

We studied 215 subjects from a random sample of 432 people who had declared to suffer from dyspnea. These 432 subjects were referred to their hospital where blood samples were taken, an echo-Doppler study was performed and a specific questionnaire was completed. We got a positive answer from 215, and 52 (24%) have LV hypertrophy.

RESULTS

When we compared NT-proBNP in non-hypertrophic population, 148 +/- 286 pg/ml, with NT-proBNP in LV hypertrophic population, 202 +/- 209 pg/ml, we found P < 0.001. In the hypertrophic group, when we compared NT-proBNP (199 +/- 201 pg/ml) in normotensive subjects (LV mass index 170 +/- 70 g/m2, Vp 50 +/- 18 cm/s, LVEF 62 +/- 8) with NT-proBNP (205 +/- 220 pg/ml) in subjects with diagnosis of HT (LV mass index 169 +/- 37 g/m2, Vp 55 +/- 20 cm/s, LVEF 64 +/- 10), we found NS.

CONCLUSIONS

This population study shows that NT-proBNP is elevated in patients with LV hypertrophy with or without HT. In LV hypertrophy the presence of HT does not influence the peptide levels significantly.

Usefulness of left atrial volume as a predictor of mortality in patients with ischemic cardiomyopathy

Left atrial (LA) volume is a load-independent marker of left ventricular diastolic function. To determine the value of LA volume to predict mortality in patients with ischemic cardiomyopathy, clinical and echocardiographic variables, including Doppler parameters, were evaluated in 109 patients with ischemic cardiomyopathy. LA volume was the only independent predictor of mortality (hazard ratio 1.03, 95% confidence interval 1.001 to 1.057, p = 0.03).

Early and subtle abnormalities of left ventricular function in clinically stable coronary artery disease patients with normal ejection fraction

BACKGROUND

It has been reported that, in the initial phase of ischemic cardiomyopathy, the earliest alterations of left ventricular function are detected during the relaxation phase. The aim of this study was to look for precocious abnormalities in the early stage of ischemic cardiomyopathy in both left ventricular systolic and diastolic phases.

METHODS AND RESULTS

Using simultaneous left ventricular catheterization and echo-Doppler techniques, we studied both systolic and diastolic function in 44 (37 males and 7 females, mean age 55.7+/-8) normotensive, clinically stable, coronary artery disease patients with normal left ventricular ejection fraction in comparison to 9 age- and sex-matched normal control subjects (7 males and 2 females, mean age 54.7+/-9). Mean values of E deceleration time, tau, left ventricular end-diastolic volume and pressure, and end-systolic volume and lowest diastolic pressure were significantly higher (from P<.05 to P<.01), whereas mean dP/dt/P values significantly lower (P<.05) in coronary artery disease patients than in controls. A strict relationship (P<.001) between dP/dt/P and tau, left ventricular lowest and end-diastolic pressure was found in all subjects studied.

CONCLUSION

Early and subtle abnormalities in parameters of both systolic and diastolic function can be found in the majority of coronary artery disease patients with normal ejection fraction.

Amino-terminal propeptide of type III procollagen is associated with restrictive mitral filling pattern in patients with dilated cardiomyopathy: a possible link between diastolic dysfunction and prognosis

OBJECTIVE

To analyse the relation between restrictive mitral pattern, amino-terminal propeptide of type III procollagen (PIIINP), and prognosis in patients with dilated cardiomyopathy.

DESIGN

Prospective cohort study of 106 patients with dilated cardiomyopathy.

SETTING

Tertiary care centre.

MAIN OUTCOME MEASURES

PIIINP concentration, echocardiographic variables, oxygen consumption, hospitalisation for heart failure, and cardiac mortality were evaluated in patients grouped by the presence of non-restrictive (group 1), reversible (group 2), and irreversible restrictive mitral pattern (group 3).

RESULTS

Groups differed regarding left ventricular ejection fraction (group 1, mean (SD) 36 (6)%, group 2, 29 (8)%, group 3, 25 (6)%; p = 0.0001), left atrial ejection fraction (group 1, 0.47 (0.1)%, group 2, 0.43 (0.2)%, group 3, 0.26 (0.1)%; p < 0.0001), and PIIINP (p = 0.001). Multivariate analysis showed that PIIINP was related to mitral pattern (odds ratio 0.8, 95% confidence interval 0.23 to 1.4, p = 0.006) independently of left atrial and ventricular ejection fractions. After 21 months, survival was 88% and 34% (p = 0.0001) in patients with non-restrictive and irreversible restrictive mitral patterns, respectively.

CONCLUSION

In patients with dilated cardiomyopathy, restrictive mitral pattern is associated with higher PIIINP and worse prognosis.

Tachycardia during the valsalva maneuver: a sign of normal diastolic filling pressures

Alteration of the loading conditions during the Valsalva maneuver is a helpful ancillary method in the noninvasive assessment of diastolic filling of the heart by Doppler echocardiography. When tachycardia is induced by the maneuver, mitral inflow velocity curves may become uninterpretable because of E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and A velocity (the velocity at atrial contraction on the transmitral flow velocity curve) wave fusion. To determine the clinical significance of the E velocity and A velocity wave fusion, our study assessed the relation between the heart rate response induced by the Valsalva maneuver and the left ventricular filling pressures measured during cardiac catheterization. In all, 77 patients performed the maneuver during continuous hemodynamic and electrocardiographic monitoring. The ratio between the baseline R-R interval and the shortest R-R interval during the maneuver was calculated. A ratio value higher than 1.1 was predictive of a pre-A pressure of less than 18 mm Hg (94% positive predictive value). Reflex tachycardia during the Valsalva maneuver and subsequent fusion of the E velocity and A velocity waves on the mitral velocity curves is a sign of normal left ventricular filling pressures.

Potentials and limitations of color M-Mode and tissue Doppler indexes in identifying pseudonormal mitral filling pattern in patients with acute symptoms of heart failure and preserved left ventricular systolic function

The aim of this study was to assess the accuracy of flow propagation velocity by color M-mode (Vp) and peak early diastolic mitral annulus velocity by tissue Doppler (Ea) in identifying pseudonormal mitral filling in 25 patients with acute symptoms of heart failure and preserved left ventricular systolic function compared with 25 gender- and age-matched healthy subjects. Although normal velocities for both Vp and Ea were found in 40% of patients, E/Vp and E/Ea ratios were able to differentiate pseudonormal from normal filling irrespective of values for Vp and Ea.

Noninvasive estimation of left ventricular filling pressure by e/e′ is a powerful predictor of survival after acute myocardial infarction

OBJECTIVES

The aim of this study was to assess the prognostic value of a noninvasive measure of left ventricular diastolic pressure (LVDP) early after acute myocardial infarction (MI).

BACKGROUND

The early diastolic velocity of the mitral valve annulus (e') reflects the rate of myocardial relaxation. When combined with measurement of the early transmitral flow velocity (E), the resultant ratio (E/e') correlates well with mean LVDP. In particular, an E/e' ratio >15 is an excellent predictor of an elevated mean LVDP. We hypothesized that an E/e' ratio >15 would predict poorer survival after acute MI.

METHODS

Echocardiograms were obtained in 250 unselected patients 1.6 days after admission for MI. Patients were followed for a median of 13 months. The end point was all-cause mortality.

RESULTS

Seventy-three patients (29%) had an E/e' >15. This was associated with excess mortality (log-rank statistic 21.3, p < 0.0001) and was the most powerful independent predictor of survival (risk ratio 4.8, 95% confidence interval 2.1 to 10.8, p = 0.0002). The addition of E/e' >15 improved the prognostic utility of a model containing clinical variables and conventional echocardiographic indexes of left ventricular systolic and diastolic function (p = 0.001).

CONCLUSIONS

E/e' is a powerful predictor of survival after acute MI. An E/e' ratio >15 is superior, in this respect, to other clinical or echocardiographic features. Furthermore, it provides prognostic information incremental to these parameters.

The Prevalence of Preoperative Diastolic Filling Abnormalities in Geriatric Surgical Patients

Preoperative assessment of heart function has typically focused on evaluating left ventricular ejection fraction (LVEF). Recent evidence suggests that diastolic heart failure is common and may cause substantial morbidity and mortality. We designed this study to examine the prevalence and potential clinical correlates of diastolic filling abnormalities as measured by echocardiography in geriatric surgical patients. Patients >=65 yr of age undergoing coronary artery surgery without concomitant valvular surgery or those with one or more risk factors for cardiovascular disease undergoing noncardiac surgery were prospectively studied. Preoperative precordial echocardiography was performed for patients undergoing noncardiac surgery, and intraoperative transesophageal echocardiography was performed for those undergoing cardiac surgery. LVEF and diastolic filling properties including E/A ratio and deceleration time were measured. Overall, 251 patients were enrolled. The mean age was 72 +/- 7 yr. Multiple linear regression analyses showed that patients with a history of myocardial infarction P = 0.021), angina pectoris (beta = -6.09, 95% CI: -9.66, -2.52; P = 0.01), and valvular heart disease (beta = -5.05, 95% CI: -9.56, -0.55; P = 0.028) had lower LVEF than those without such conditions. Of the patients with normal LVEF, 61.5% had diastolic filling abnormalities. Diastolic filling indices including E/A ratio (beta = -1.11, 95% CI -6.02, 3.78; P = 0.65) and deceleration times (beta = -3.42, 95% CI -31.28, 24.45; P = 0.81) contributed no additional predictive value for LVEF. No clinical predictors could be identified to predict diastolic filling abnormalities. For patients undergoing noncardiac surgery, analysis of variance demonstrates that the clinical assessment of LVEF using history and physical examination data was able to grossly discriminate the different levels of LVEF as compared with echocardiography (P = 0.0004). However, under-estimation of LVEF occurred more frequently than over-estimation. Although physicians' clinical assessment of systolic ejection fraction was generally accurate, geriatric patients with normal LVEF often had isolated diastolic filling abnormalities that could not be predicted by clinical factors. These results suggest that evaluation of LV systolic function alone is not discriminatory in comprehensively characterizing LV function in geriatric surgical patients.

IMPLICATIONS

Although physicians' clinical assessment of systolic ejection fraction was generally accurate, geriatric patients with normal left ventricular (LV) ejection fraction often had isolated diastolic filling abnormalities that could not be predicted by clinical factors. These results suggest that evaluation of LV systolic function alone is not discriminatory in comprehensively characterizing LV function in geriatric surgical patients.

Association of newer diastolic function parameters with age in healthy subjects: a population-based study

OBJECTIVES

We sought to determine if newer Doppler diastolic function parameters are associated with age and to define age-stratified reference ranges for these parameters in a population-based setting.

BACKGROUND

Although newer Doppler parameters aid in the evaluation of diastolic function and filling pressures, age-specific reference ranges are poorly described.

METHODS

Randomly selected residents of Olmsted County, Minn, age >/= 45 years were studied (n = 2042) prospectively. Those without a history of cardiovascular disease or abnormal 2-dimensional echocardiograms were selected. Measured parameters included the transmitral early (E) and late (A) filling velocities at rest and with Valsalva, A duration, pulmonary venous atrial reversal duration, lateral and septal early diastolic mitral annular velocities, E/lateral early diastolic mitral annular velocity, E/septal early diastolic mitral annular velocity, and the index of left ventricular myocardial performance.

RESULTS

A total of 1012 subjects met the inclusion criteria. Both A duration (r = 0.18, P <.001) and pulmonary venous atrial reversal duration (r = 0.28, P <.001) were longer in older subjects, whereas their difference showed a marginal correlation with age (r = 0.07, P =.036). The E/A ratio at peak Valsalva correlated with age (r = -0.54, P <.001) whereas the change in E/A with Valsalva (corrected for E-A fusion) showed a marginal correlation with age (r = 0.08, P =.032). Both E/lateral early diastolic mitral annular velocity (r = 0.39, P <.001) and E/septal early diastolic mitral annular velocity (r = 0.27, P <.001) increased with age. Left ventricular myocardial performance showed a marginal correlation with age (r = 0.08, P =.014). Age specific reference ranges (median, 5th and 95th percentiles) for all parameters are provided.

CONCLUSIONS

All newer Doppler diastolic function parameters showed a variable but significant correlation with age. Age-specific reference values will aid in the interpretation of diastolic function parameters.

Pioglitazone: cardiovascular effects in prediabetic patients

Pioglitazone is the second thiazolidine derivative used clinically in the type 2 diabetes mellitus (DM). In the prediabetic stage, hyperinsulinemia or insulin resistance has been suggested to be closely associated with the oxidative stress. The first thiazolidine derivative used to treat DM, troglitazone, is chemically related to alpha-tocopherol, a known antioxidant. Troglitazone prevents tissue damage, but has been reported to produce hepatotoxicity. Pioglitazone strongly increases insulin sensitivity, improves glucose and lipid metabolism and showed no evidence of hepatotoxicity. The mechanism of the antidiabetic action of pioglitazone involves activation of insulin receptors and/or high affinity for peroxisome proliferator-activated receptor gamma (PPARgamma). Hydroxylation of the phenyl and pyridine rings in the chemical structure of pioglitazone may facilitate the scavenging of hydroxyl radicals. The direct antioxidant effect of pioglitazone may contribute to its effect on insulin resistance. The hypoglycemic and hypolipidemic effects of pioglitazone are likely to reduce the expression of TNFalpha. The reduction in the oxidative stress may lead to the suppression of TGFbeta and of collagen accumulation. A decrease in collagen content is likely to improve left ventricular diastolic function and distensibility of the aortic wall. Reduction in the oxidative stress may prevent the proliferation of vascular smooth muscle cells and contribute to the decrease in the aortic wall stiffness.

Left atrial volume: a powerful predictor of survival after acute myocardial infarction

BACKGROUND

After acute myocardial infarction (AMI), diastolic function assessed by Doppler echocardiography provides important prognostic information that is incremental to systolic function. However, Doppler variables are affected by multiple factors and may change rapidly. In contrast, left atrial (LA) volume is less influenced by acute changes and reflects subacute or chronic diastolic function. This may be of importance when one assesses risk in patients with AMI.

METHODS AND RESULTS

Three hundred fourteen patients with AMI who had a transthoracic echocardiogram with assessment of left ventricular (LV) systolic and diastolic function and measurement of LA volume during admission were identified. The LA volume was corrected for body surface area, and the population was divided according to LA volume index of 32 mL/m2 (2 SDs above normal). LA volume index was >32 mL/m2 in 142 (45%). The primary study end point was all-cause mortality. During follow-up of 15 (range 0 to 33) months, 46 patients (15%) died. LA volume index was a powerful predictor of mortality and remained an independent predictor (hazard ratio 1.05 per 1-mL/m2 change, 95% CI 1.03 to 1.06, P<0.001) after adjustment for clinical factors, LV systolic function, and Doppler-derived parameters of diastolic function.

CONCLUSIONS

Increased LA volume index is a powerful predictor of mortality after AMI and provides prognostic information incremental to clinical data and conventional measures of LV systolic and diastolic function.

Doppler tissue imaging: regional myocardial function in hypertrophic cardiomyopathy and in athlete's heart

BACKGROUND

The distinction between hypertrophic cardiomyopathy (HCM) and the athlete's (AT) heart is an important clinical problem, and the analysis of regional myocardial function with Doppler tissue imaging may be useful in the differential diagnosis.

OBJECTIVE

Our aim was to compare regional function assessed by Doppler tissue imaging in rowers and in a group of patients with HCM.

METHODS

In 24 patients with nonobstructive HCM and in 20 competitive rowers with similar age, blood pressure, and heart rate, we analyzed with pulsed Doppler tissue imaging left ventricular (LV) regional function (velocities, time intervals, heterogeneity and asynchrony indices, and meridional gradient) in the longitudinal (8 segments, apical views) and in the radial (2 segments, short-axis view) axis.

RESULTS

Compared with AT, patients with HCM showed: (1). systolic function; (a). longitudinal: lower velocities and meridional gradient; longer precontraction period (PCP); and higher PCP/LV contraction time; (b). radial: lower velocities and gradient; longer PCP; and higher PCP/LV contraction time; (2.diastolic function; (a). logitudinal: lower e (early diastolic), a (late diastolic), and e/a velocities; and longer prerelaxation time and time to peak e. The percentage of segments with e/a < 1 was 25% in the HCM group and 0% in the AT heart group; (b). radial: lower e velocity and gradient; lower e/a gradient; and longer medial prerelaxation and basal time to peak e. Most of these differences also occurred in the nonhypertrophied inferior wall of patients with HCM.

CONCLUSIONS

There are significant differences between regional LV function of competitive rowers and patients with HCM. These differences (1). occur in systole and diastole; (2). affect velocities and time intervals; (3). are more striking in the long axis, but are also seen in the short axis, and (4). also occur in nonhypertrophied segments, suggesting the usefulness of the technique in the differential diagnosis between the 2 situations, namely in individuals that fall in Maron's "grey zone."

Intraoperative assessment of diastolic function: utility of echocardiography

PURPOSE OF REVIEW

This review discusses the current and future applications of different echocardiographic modalities in evaluating diastolic function intraoperatively.

RECENT FINDINGS

Normal diastolic function is required for optimal cardiac performance. There is sufficient evidence to support the significant prevalence of preoperative diastolic dysfunction and its incidence following cardiac surgery, however controversy still exists regarding the impact of diastolic dysfunction on adverse outcomes. Echocardiography provides a relatively safe, practical and noninvasive means to evaluate perioperative diastolic function, however conventional measures may be limited by the impact of changes in heart rate, rhythm and loading conditions. Newer echocardiographic modalities are reportedly less sensitive to acute changes in loading conditions, and may therefore complement the use of conventional echocardiographic techniques in the perioperative period.

SUMMARY

The availability of effective technology for diagnosing the presence and progression of perioperative diastolic function should assist in the identification of high-risk cardiac surgical patients who may benefit from appropriate triaging and therapeutic intervention.

Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic

CONTEXT

Approximately half of patients with overt congestive heart failure (CHF) have diastolic dysfunction without reduced ejection fraction (EF). Yet, the prevalence of diastolic dysfunction and its relation to systolic dysfunction and CHF in the community remain undefined.

OBJECTIVES

To determine the prevalence of CHF and preclinical diastolic dysfunction and systolic dysfunction in the community and determine if diastolic dysfunction is predictive of all-cause mortality.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional survey of 2042 randomly selected residents of Olmsted County, Minnesota, aged 45 years or older from June 1997 through September 2000.

MAIN OUTCOME MEASURES

Doppler echocardiographic assessment of systolic and diastolic function. Presence of CHF diagnosis by review of medical records with designation as validated CHF if Framingham criteria are satisfied. Subjects without a CHF diagnosis but with diastolic or systolic dysfunction were considered as having either preclinical diastolic or preclinical systolic dysfunction.

RESULTS

The prevalence of validated CHF was 2.2% (95% confidence interval [CI], 1.6%-2.8%) with 44% having an EF higher than 50%. Overall, 20.8% (95% CI, 19.0%-22.7%) of the population had mild diastolic dysfunction, 6.6% (95% CI, 5.5%-7.8%) had moderate diastolic dysfunction, and 0.7% (95% CI, 0.3%-1.1%) had severe diastolic dysfunction with 5.6% (95% CI, 4.5%-6.7%) of the population having moderate or severe diastolic dysfunction with normal EF. The prevalence of any systolic dysfunction (EF < or =50%) was 6.0% (95% CI, 5.0%-7.1%) with moderate or severe systolic dysfunction (EF < or =40%) being present in 2.0% (95% CI, 1.4%-2.5%). CHF was much more common among those with systolic or diastolic dysfunction than in those with normal ventricular function. However, even among those with moderate or severe diastolic or systolic dysfunction, less than half had recognized CHF. In multivariate analysis, controlling for age, sex, and EF, mild diastolic dysfunction (hazard ratio, 8.31 [95% CI, 3.00-23.1], P<.001) and moderate or severe diastolic dysfunction (hazard ratio, 10.17 [95% CI, 3.28-31.0], P<.001) were predictive of all-cause mortality.

CONCLUSIONS

In the community, systolic dysfunction is frequently present in individuals without recognized CHF. Furthermore, diastolic dysfunction as rigorously defined by comprehensive Doppler techniques is common, often not accompanied by recognized CHF, and associated with marked increases in all-cause mortality.

Comparison between invasive hemodynamic measurements and noninvasive assessment of left ventricular diastolic function by use of Doppler echocardiography in healthy anesthetized cats

OBJECTIVE

To compare Doppler echocardiographic variables of left ventricular (LV) function with those obtained invasively via cardiac catheterization under a range of hemodynamic conditions.

ANIMALS

7 healthy anesthetized cats (1 to 3 years of age).

PROCEDURE

Cats were anesthetized and instrumented to measure the time constant of isovolumic relaxation (tau [tau]), LV end-diastolic pressure (LVEDP), peak negative and positive rate of change of LV pressure, arterial blood pressure, and cardiac output. Echocardiographic variables of diastolic function (isovolumic relaxation time [IVRT], early LV flow propagation velocity [Vp], transmitral and pulmonary venous flow velocity indices, and LV tissue Doppler imaging indices) were measured simultaneously over a range of hemodynamic states induced by treatments with esmolol, dobutamine, cilobradine, and volume loading. Correlation between invasive and noninvasive measures of LV filling was determined by univariate and multivariate regression analyses.

RESULTS

Significant correlations were found between tau and IVRT, peak Vp, peak late transmitral flow velocity, and peak systolic pulmonary venous flow velocity. A significant correlation was found between LVEDP and early diastolic transmitral flow velocity (peak E) and the ratio of peak E to peak Vp, but not between LVEDP and peak Vp.

CONCLUSIONS AND CLINICAL RELEVANCE

IVRT and Vp can be used as noninvasive indices of LV relaxation; Vp was independent of preload and heart rate in this study. The E:Vp ratio may be useful as an indicator of LV filling pressure.

[Usefulness of Doppler echocardiography in the diagnosis of acute diastolic heart failure in the elderly]

PURPOSE

To evaluate the clinical usefulness of the determination of Doppler mitral inflow pattern and new combined indices using colour M mode velocity flow propagation (Vp) in the diagnosis of acute diastolic heart failure in the elderly.

METHODS

Total serum protein concentration (P, g/l) and E/A, E/Vp and 1000/(2 x IRT + Vp) Doppler indices (E and A: mitral inflow peak velocities; IRT: isovolumic relaxation time) were measured at the time of therapy initiation in 94 patients with left ventricular ejection fraction > 50% (78 +/- 13 years), 56 with pulmonary edema and 38 patients with acute respiratory disease.

RESULTS

The feasibility was 73, 90 and 89% for E/A, E/Vp and 1000/(2 x IRT + Vp) respectively. The sensitivity, specificity and accuracy were 94-56-72%, 84-86-85% and 92-86-89% for E/A > or = 1, E/Vp > or = 2 and 1000/(2 x IRT + Vp) > or = 6 respectively in the diagnosis of pulmonary edema in patients with normal serum colloid osmotic pressure defined by P > or = 60 g/l, and 41-50-43%, 37-86-50% and 22-100-42% in patients with low colloid osmotic pressure (P < 60 g/l).

CONCLUSIONS

The mitral inflow measurement is limited in most of cases of acute diastolic heart failure in the elderly by confounding factors such as atrial fibrillation and normalised pattern. New combined Doppler indices are useful in these patients, however, their value must be interpreted according to the serum colloid osmotic status estimated by total serum protein concentration.

Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy

OBJECTIVES

We aimed to investigate the determinants of left atrial (LA) volume and its prognostic value in patients with dilated cardiomyopathy (DCM).

BACKGROUND

Enlargement of the LA is a marker of mortality in the general population. Patients with DCM are characterized by a wide range of LA sizes, but the clinical role of this observation has been played down.

METHODS

A complete echocardiographic Doppler examination was performed in 337 patients (age 60 +/- 13 years; 84% male) with the diagnosis of DCM. Left atrial maximal volume (LA(max)) was measured at left ventricular (LV) end systole (four-chamber view; area-length method). Left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) were also measured. Mitral regurgitation (MR) was graded using a 5-point scale. Mitral E-wave (E) and A-wave (A) velocities, as well as their ratio (E/A), were measured off-line.

RESULTS

Determinants of LA(max) were: atrial fibrillation (r = 0.34, p < 0.0001), LVEDV (r = 0.46, p < 0.0001), EF (r = 0.40, p < 0.0001), MR (r = 0.39, p < 0.0001), and E/A ratio (r = 0.36, p < 0.0001). During follow-up (41 +/- 29 months), 77 patients died and 12 underwent heart transplantation. Univariate Cox analysis showed that LA(max) (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.007-1.013, p < 0.0001), LVESV (HR 1.003, CI 1.001-1.005, p = 0.0003), E/A ratio (HR 1.6, CI 1.3-2.005, p < 0.0001), and MR (HR 1.21, CI 1.03-1.44, p = 0.02) were related to the outcome. On bivariate Cox analysis, LA(max) predicted the prognosis independently of each determinant. Patients with a larger LA volume (LA(max)/m(2) >68.5 ml/m(2)) had a risk ratio of 3.8 compared with those with a smaller LA volume.

CONCLUSIONS

In patients with DCM, LA volume is associated with LV remodeling, diastolic dysfunction, and the degree of MR. The maximal volume of the LA has an independent and incremental prognostic value, compared with all its determinants.

Mitral annulus velocities by Doppler tissue imaging: practical implications with regard to preload alterations, sample position, and normal values

Because it appears to be less affected by changes in preload, mitral annulus Doppler tissue imaging (DTI) has been proposed as an alternate mean of identifying pseudonormal patterns of left ventricular filling. We thus studied the practical implications of DTI in 40 patients classified according to the Canadian Consensus on Diastolic Function (9 control participants, 9 with impaired relaxation, and 22 pseudonormal participants). Using DTI, the early diastolic velocity (Ea) was the most reproducible parameter whereas the late diastolic velocity (Aa) and Ea/Aa ratio varied significantly. Nonetheless, Ea missed 23% of pseudonormal participants and its sensitivity, specificity, and positive and negative predictive values to identify diastolic dysfunction were 81%, 89%, 96%, and 57%, respectively; improving to 94%, 89%, 97%, and 80%, respectively, if used during Valsalva's maneuver. Thus, DTI is not totally preload independent and should be interpreted in light of the other Doppler parameters and the use of Valsalva's maneuver. Moreover, consistent with recent studies, these results suggest that the threshold value of Ea used to identify diastolic dysfunction should be approximately 12.5 cm/s.

The role of short- and long-axis function in determining late diastolic left ventricular filling in patients with hypertension: assessment by pulsed Doppler tissue imaging

Left ventricular (LV) wall motion velocity during atrial systole is mediated by both transmitral flow and LV myocardial compliance at end-diastole. LV wall distensibility along the long- and short-axis during atrial systole and late diastolic LV filling may vary according to the remodeling of LV morphology. We measured LV wall motion velocities along the long and short axes using pulsed Doppler tissue imaging in 127 patients with hypertension to evaluate the relationship between the hemodynamic changes and LV morphology and to determine the role of both long- and short-axis function in late diastolic LV filling. Participants were classified into 3 groups according to LV dimension and end-diastolic wall thickness determined by M-mode echocardiography: group A (n = 62) without LV dilation or hypertrophy, group B (n = 55) with LV hypertrophy, and group C (n = 10) with LV dilation and systolic dysfunction. The time constant of the LV pressure decay during isovolumic diastole and the LV end-diastolic pressure were longest and greatest, respectively, in group C, compared with groups B and A. There were no significant differences in active left atrial emptying volume during atrial contraction determined by computerized echocardiographic 3-dimensional reconstruction among patient and control groups. The peak atrial systolic motion velocity of the LV posterior wall along the long axis was significantly lower in groups B and C, particularly in the latter group, than in group A. The peak atrial systolic motion velocity of the LV posterior wall along the short axis was greatest in group B and was lowest in group C compared with the other groups, respectively. The peak atrial systolic motion velocity of the LV posterior wall was greater along the long axis than the short axis in group A, but was less than the short axis in group B. In conclusion, the long- and short-axis function of the LV wall during atrial systole varies in patients with hypertension according to the severity of hemodynamic and morphologic abnormalities. The degree of LV wall expansion along the short axis is an important factor resulting from the atrial kick, and a determinant of its effectiveness.

Plasma brain natriuretic peptide concentration: impact of age and gender

OBJECTIVES

We wished to examine the effects of age and gender on plasma brain natriuretic peptide (BNP) concentration in a population-based study.

BACKGROUND

Measurement of BNP concentration is approved for use in the diagnosis of heart failure and may aid in the detection of left ventricular dysfunction. Although BNP is approved for clinical use, there are few data regarding the range of BNP observed in persons without cardiovascular disease or cardiac dysfunction. These data are essential for the interpretation of BNP.

METHODS

In 2,042 randomly selected residents of Olmsted County, Minnesota, >44 years old, BNP (Shionogi and Biosite assays), Doppler echocardiography, and medical record review were performed. A normal subset of subjects (n = 767) in sinus rhythm without cardiovascular, renal, or pulmonary disease or diabetes; on no cardiovascular medications; and with normal systolic, diastolic, and valvular function was identified.

RESULTS

Within the normal subset, the distribution of BNP differed by age, gender, and assay system. With both assays, BNP increased significantly with age and was significantly higher in women than men, leading to age-, gender-, and assay-specific reference ranges. Receiver operating characteristic analysis for the ability of BNP to detect an ejection fraction < or = 40% was performed in each age/gender stratum in the entire cohort (n = 2,042) and confirmed that discriminatory values for BNP for detection of reduced ejection fraction were higher in women and older persons and were different between the two assays.

CONCLUSIONS

Interpretation of BNP should include consideration of age-, gender-, and assay-specific partition values.

Mitral flow propagation velocity identifies patients with abnormal diastolic function during coronary artery bypass graft surgery

Flow propagation velocity (Vp) is a new method of assessing left ventricular (LV) diastolic (D) function that seems to be insensitive to heart rate and preload changes. We hypothesized that Vp <50 cm/s identifies patients with D dysfunction and that Vp provides an assessment of D function when standard Doppler techniques are uninterpretable. We conducted a prospective Doppler echocardiographic assessment of D function in 63 patients undergoing coronary artery bypass graft surgery. Doppler derivatives of mitral inflow and pulmonary vein flow profiles as well as isovolumic relaxation time were compared with Vp before and after cardiopulmonary bypass. A Valsalva maneuver was used to decrease preload. All patients with D dysfunction had Vp <50 cm/s. A Valsalva maneuver did not affect Vp. Vp remained a reliable measure of LV D function when mitral flow profiles could not be determined because of changes in heart rate and rhythm. LV filling patterns did not change significantly after cardiopulmonary bypass. We conclude that Vp is a simple measure of D function during coronary artery bypass graft surgery that correlates with standard, load-dependent Doppler echocardiographic techniques to identify D dysfunction. Vp <50 cm/s identifies abnormal D function in this patient population.

IMPLICATIONS

Mitral propagation velocity (Vp) is a simple, reproducible measure of diastolic function during coronary artery bypass graft surgery that correlates with standard Doppler echocardiographic techniques to identify dysfunction in the setting of a rapid heart rate or variable preload. Vp <50 cm/s identifies abnormal diastolic function in this patient population.

Analysis of left atrial volume change rate during left ventricular diastolic phase with M-mode echocardiography for differentiation between normal and pseudonormal mitral inflow

Pseudonormalization of mitral inflow is a diagnostic problem in clinical practice. An excellent correlation exists between the change in the left atrial (LA) angiographic area and posterior aortic wall motion. Therefore, we sought to define the role of LA wall motion, indicating LA volume change rate, in patients with normal and pseudonormal mitral inflow. We performed echocardiography after cardiac catheterization in 62 patients with a velocity ratio of early-to-late mitral inflow (E/A ratio) >1. Study patients were classified into 2 groups according to the response of mitral inflow to phase II of the Valsalva maneuver: patients with E/A >1 after the Valsalva maneuver (n = 31, control group), and patients with <1 after the Valsalva maneuver (n = 31, pseudonormal group). The slopes (slope E and A) of early diastolic and late diastolic motion of the LA wall were derived from M-mode analysis together with the time constant of left ventricular (LV) isovolumic relaxation from cardiac catheterization. The values of slope E (41 plus minus 11 vs 61 plus minus 12 mm/s, p <0.001) and slope E/A (0.69 plus minus 0.13 vs 1.32 plus minus 0.35, p <0.001) were significantly lower in the pseudonormal group and were inversely correlated with the time constant of LV isovolumic relaxation (r = 0.64, p <0.001 and r = 0.73, p <0.001, respectively). Using slope E/A <1 as an indicator of relaxation abnormality, the sensitivity, specificity, positive predictive value, and negative predictive value for the detection of pseudonormalization were 94%, 100%, 100%, and 94%, respectively. The slope of LA wall motion, indicating LA volume change rate, during the LV diastolic phase is useful for evaluating pseudonormal LV diastolic dysfunction in the selected patient population.

Losartan treatment and left ventricular filling during volume loading in patients with dilated cardiomyopathy

BACKGROUND

Patients with mild heart failure show a reduction in preload reserve mechanism during volume expansion. At this time, the effects of volume expansion on left ventricular (LV) diastolic filling in this subset of patients have not been well characterized.

METHODS

We evaluated the effects of acute volume loading on Doppler parameters of LV filling in 10 healthy control subjects and in 12 patients with idiopathic dilated cardiomyopathy (DCM). In patients with DCM, the effects of losartan on diastolic adaptation to volume load were also investigated.

RESULTS

During volume loading, the healthy control subjects showed a decrease in isovolumic relaxation time (F = 5.3, P <.05) but an increase in the LV peak filling rate (F = 52.9, P <.001) and velocity time integral of both systolic (F = 72.8, P <.001) and diastolic (F = 4.6, P <.05) pulmonary venous flow. In patients with DCM, isovolumic relaxation time decreased more than in control subjects (F = 8.1, P <.01), and the deceleration time of the early mitral wave was reduced (F = 26.3, P <.001). Furthermore, the duration of pulmonary venous flow reversal exceeded that of mitral flow at atrial contraction (F = 28.5, P <.001). After treatment with losartan, the deceleration time of early mitral wave remained unchanged, and the duration of pulmonary venous flow reversal at atrial contraction did not exceed that of mitral flow; thus, a significant treatment effect was detectable (F = 5.6, P <.05; and F = 6.6, P <.05, respectively).

CONCLUSIONS

Control subjects respond to volume load with enhancement in early LV filling, whereas patients with DCM show an increase of LV filling pressure. Diastolic adaptation to volume load improves in patients with DCM after treatment with losartan.

Pioglitazone improves left ventricular diastolic function and decreases collagen accumulation in prediabetic stage of a type II diabetic rat

This study investigated the effect of pioglitazone, an insulin sensitizer, on metabolic abnormalities and oxidative stress as a cause of myocardial collagen accumulation in prediabetic rat hearts. Twenty male diabetic rats and 9 male nondiabetic age-matched rats were used. The diabetic rats were divided into two groups: diabetic treated and untreated. Pioglitazone was mixed in rat chow fed to the diabetic treated group (0.01%). Treatment duration was 5 weeks. At baseline (15 weeks) and 20 weeks of age, blood glucose, lipid, insulin, and plasma malondialdehyde-thiobarbituric acid (MDA) levels were measured and Doppler echocardiography was tracked. At 20 weeks of age, left ventricular collagen content was studied. Blood glucose, plasma insulin, and triglyceride levels in the diabetic treated group were significantly lower than those in the untreated diabetic group. Deceleration time (ms) of early diastolic inflow in the treated diabetic group decreased significantly compared with the untreated diabetic group (65 +/- 8 vs. 77 +/- 8, p < 0.01). Ratio of left ventricular weight to body weight (mg/g) and ratio of left ventricular collagen content to dry weight (mg/100 mg) were decreased in the treated diabetic group (1.5 +/- 0.1, 1.3 +/- 0.3) compared with the untreated diabetic group (1.7 +/- 0.2, p < 0.01; 1.7 +/- 0.3, p < 0.05). Plasma MDA concentration (nmol/ml) significantly decreased (2.9 +/- 0.3 at baseline to 2.3 +/- 0.3 at 20 weeks, p = 0.001) in the treated diabetic group, and was lower than that in the untreated diabetic group (3.2 +/- 0.7 at 20 weeks, p < 0.05). Pioglitazone improved glucose and lipid metabolism and reduced oxidative stress in the left ventricle, which decreased left ventricular collagen accumulation and improved left ventricular diastolic function of prediabetic rat hearts.

Effect of the Valsalva manoeuver on diastolic filling indices in patients with essential hypertension

In some hypertensive patients, echocardiographic examination does not reveal any pathologic finding in spite of a documented blood pressure elevation. In our study, we investigated the effect of preload reduction with Valsalva manoeuver on transmitral flow velocities in hypertensive patients with normal mitral flow pattern and compared the results with a healthy control group. Sixty-eight patients without evidence of coronary artery disease or heart failure (28 female, 40 male, age 50 +/- 7) were divided in two groups according to their E/A ratio as those with diastolic dysfunction (n = 36) and without diastolic dysfunction (DD(-): n = 32). DD(-) patients and the control group (n = 20) performed Valsalva manoeuver and their pulsed-Doppler mitral flow measurements were repeated at the strain phase. During Valsalva manoeuver, E wave velocity decreased in all subjects. In the controls, peak A velocity showed a similar decline and E/A ratio remained over 1.0. However, in 72% of DD(-) patients A velocity did not change or increased and their E/A ratio fell below 1.0. In 47% of the patients with an E/A ratio reversal after Valsalva manoeuver, myocardial perfusion scintigraphy revealed reversible defects whereas none of the patients whose E/A ratio remained over 1.0 had perfusion defects. It is concluded that: (1) in hypertensive patients with normal E/A ratio Valsalva manoeuver should be performed in order to unmask a probable false normal finding, (2) an important percent of hypertensive individuals have left ventricular relaxation abnormalities, and (3) diastolic dysfunction develops together with a decrease in coronary reserve.

Echocardiographic assessment of diastolic function

Abnormal diastolic function is increasingly appreciated as a major contributor to cardiac morbidity and mortality. Accurate noninvasive assessment of the presence and severity of diastolic impairment is crucial to the broad application and understanding of this common condition. Echocardiographic parameters have become the backbone of this noninvasive assessment. Active investigation into both old and new Doppler variables will provide the framework that can lead to a more uniform assessment and reporting that will be essential as we prepare to confront clinically the next frontier in cardiac pathophysiology. This review discusses the clinical impact of recent echocardiographic contributions to the field of diastology.

Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study

BACKGROUND

Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether mitral annular velocities as assessed by tissue Doppler imaging are associated with invasive measures of diastolic LV performance and whether additional information is gained over traditional Doppler variables.

METHODS AND RESULTS

One hundred consecutive patients referred for cardiac catheterization underwent simultaneous Doppler interrogation. Invasive measurements of LV pressures were obtained with micromanometer-tipped catheters, and the mean LV diastolic pressure (M-LVDP) was used as a surrogate for mean left atrial pressure. Doppler signals from the mitral inflow, pulmonary venous inflow, and TDI of the mitral annulus were obtained. Isolated parameters of transmitral flow correlated with M-LVDP only when ejection fraction <50%. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/E') showed a better correlation with M-LVDP than did other Doppler variables for all levels of systolic function. E/E' <8 accurately predicted normal M-LVDP, and E/E' >15 identified increased M-LVDP. Wide variability was present in those with E/E' of 8 to 15. A subset of those patients with E/E' 8 to 15 could be further defined by use of other Doppler data.

CONCLUSIONS

The combination of tissue Doppler imaging of the mitral annulus and mitral inflow velocity curves provides better estimates of LV filling pressures than other methods (pulmonary vein, preload reduction). However, accurate prediction of filling pressures for an individual patient requires a stepwise approach incorporating all available data.

Haematocrit profoundly affects left ventricular diastolic filling as assessed by Doppler echocardiography

BACKGROUND

The main determinants of diastolic function--pre- and afterload of the heart--are affected by the haematocrit, but the relation between haematocrit and diastolic function is unclear.

OBJECTIVE

To study the association between interindividual haematocrit values and diastolic function, by echocardiography.

DESIGN

In a cross-sectional survey, blood pressure, haematocrit values, and high-quality Doppler indexes of left ventricular filling were obtained in 1297 individuals, 25-74 years of age, and analysed by regression analyses.

RESULTS

Haematocrit and systolic blood pressure were strongly correlated (r = 0.23; P < 0.0001). Moreover, haematocrit was inversely correlated with the peak velocity of early left ventricular filling and with the peak velocity of early filling divided by late filling (E/A ratio; both P< 0.005). Left ventricular isovolumic relaxation time (IVRT) was positively associated with haematocrit (r= 0.18, P< 0.001). In individuals with an abnormal Doppler filling pattern (E/A(< 50 years) < 1, E/A(> 50 years) < 0.5, or IVRT(< 30 years) > 92 ms, IVRT30-50 years > 100 ms or IVRT> 50 years > 1 05 ms; n = 119), greater haematocrit values were observed than in those with normal diastolic parameters (P< 0.001). Conversely, individuals with an increased haematocrit (> 50% in men, > 45% in women; n = 16) had a greater risk of presenting with abnormal left ventricular filling (31.3%) compared with individuals with normal (12.1%; n = 898;) or low (< 40% in men, < 35% in women: 10.5%, n = 38; P = 0.07) haematocrit. Strong and significant associations between haematocrit and Doppler indexes of left ventricular filling were confirmed after adjustment for multiple potential confounders including blood pressure, antihypertensive medication and body mass index. Similarly, blood pressure and parameters of diastolic filling were strongly associated correlations that were not affected by inclusion of haematocrit values into the regression model.

CONCLUSION

The data point to substantial adaptations of diastolic filling in response to both blood pressure and the characteristics of the medium that is propelled by the heart Therefore, in addition to blood pressure values, the variability of haematocrit values should be considered when diastolic function is being evaluated by Doppler echocardiography.

Differentiation between reversible and irreversible restrictive left ventricular filling patterns with the use of mitral annulus velocity

A restrictive left ventricular filling pattern is generally recognized as an ominous prognostic sign in patients with congestive heart failure. Recently, this filling pattern has been further categorized into reversible and irreversible groups according to the changes in the mitral inflow pattern after preload reduction; furthermore, the prognosis is reported to be different for the two groups. Forty-two patients with a restrictive left ventricular filling pattern who could adequately perform Valsalva's maneuver were studied. Baseline peak early (E) and late (A) mitral inflow velocities, E/A ratio, deceleration time of E velocity, peak early (E') and late (A') diastolic mitral annulus velocities, and E'/A' ratio were obtained. During Valsalva's maneuver, the E/A ratio reversed (<1) in fifteen patients (15/42, 36%). These patients were categorized as belonging to the reversible group. Among the baseline mitral inflow and mitral annulus velocity parameters, A' > 0.05 m/s best discriminated between the reversible and irreversible restrictive left ventricular filling patterns, with a sensitivity of 80% and a specificity of 85%.

Preload dependence of color M-mode Doppler flow propagation velocity in controls and in patients with left ventricular dysfunction

The purpose of this study was to assess the effects of preload alterations on color M-mode flow propagation velocity (Vp) in volunteers with normal left ventricular (LV) function and in patients with depressed LV function. Color M-mode Doppler echocardiography was performed during Valsalva maneuver, passive leg lifting, and after administration of nitroglycerin in 30 healthy volunteers and in 30 age- and sex-matched patients with previous myocardial infarction (MI). Mean Vp in controls was 74 +/- 15 cm/s at baseline and 46 +/- 15 cm/s in MI patients (P <.0005). In both groups, minor changes in Vp were seen during preload alterations; however, these were not significant (control P =.72, MI P =.31). In both groups, peak E-wave velocity (P <.0005), ratio of early-to-late peak velocities (P <.0005), and E-wave deceleration time (P <.0005) were found to change during preload alterations. In conclusion, we found that in controls and patients with previous MI, the color M-mode flow propagation velocity is not affected significantly by preload.

The echo-Doppler evaluation of left ventricular diastolic function. A current perspective

The role of left ventricular (LV) diastolic function in health and disease is still incompletely understood and under appreciated by most primary care physicians and many cardiologists. Physical examination, electrocardiogram, and chest radiographs are unreliable in making the diagnosis of LV diastolic dysfunction in most individuals, and invasive measurements of cardiac pressures, rates of LV relaxation, and LV compliance are costly, clinically impracticable as they carry increased risk, and require special catheters and software analysis programs. The authors address the definition of LV diastolic dysfunction, history of diastole, LV filling patterns, pulmonary venous flow velocity variables, additional ancillary data, practical echo-Doppler evaluation of LV diastolic function, and limitations.

Unsolved problems in diastole

It is now recognized that a sizable portion of patients who exhibit symptoms of congestive heart failure have relatively well-preserved systolic function, but have significantly elevated LV filling pressures. This syndrome, termed "diastolic heart failure," is associated with various conditions such as aging, anatomic abnormalities, hypertension, ischemic disease, tachycardia, and atrial fibrillation. Advances in the proper medical and surgical management of these patients will depend on the continued delineation of the basic physiologic mechanisms that account for normal and pathologic cardiac diastolic function. This goal can only be achieved by the integration of information acquired from basic science investigations conducted in vitro and in vivo, mathematic modeling simulation studies, and prospective, community-based investigations that characterize the incidence, prevalence, and natural history of the disease. In addition, randomized clinical trials will be needed to determine the optimal treatment strategies for this group of patients--strategy choices undoubtably complicated by a disease whose treatment is influenced to a large extent by its origin. The future therapies evaluated in these randomized clinical trials will most likely range from medical therapies that target either the heart directly or the peripheral vascular system, to surgical interventions such as direct myocardial revascularization, to gene therapy. Finally, it is worth mentioning one more unresolved issue that is of general practical concern not only to the physiologist studying diastolic function, but also to the clinician: whether or not it is even feasible to develop a single, sensitive, specific, clinically relevant index of diastolic function that is free from the contaminating influences of rate, contractility, and load. As observed by Glantz 20 years ago, developing indexes with the hope that one might fully delineate the left ventricle's diastolic properties, rather than concentrating on discovering the physiologic significance of such indexes, is probably counterproductive. More recently, in a related article, Slinker implied that an operational definition of any aspect of cardiac function must allow for the measurement of that function over an adequate range of essential variables. Therefore, as previously mentioned, the physiologist studying cardiac function has the daunting task of trying to understand, in a precise way, how the processes and mechanisms of the various phases of the cardiac cycle couple together to produce either a normal or abnormal functioning heart. It seems clear that because of the complex weave of factors that control overall cardiac diastolic function, the derivation of any single index that adequately describes LV diastolic function in vivo may not be possible.

Noninvasive assessment of left ventricular end-diastolic pressure by the response of the transmitral a-wave velocity to a standardized Valsalva maneuver

Impaired relaxation is frequently masked by elevated filling pressures, resulting in a pseudonormal flow pattern (E/A >1.0). Because the E/A wave ratio increases as filling pressures rise, it is generally assumed that patients with an E/A ratio of <1.0 (impaired relaxation pattern) have relatively low filling pressures. Nevertheless, patients with an E/A ratio of <1.0 can have as profoundly elevated filling pressures as patients with a pseudonormal or restrictive filling pattern. Because left ventricular (LV) pressure during end-diastole essentially determines atrial afterload, the response of the A-wave velocity to a reduction of atrial afterload by a standardized Valsalva maneuver should allow estimation of LV end-diastolic pressure (LVEDP) regardless of the baseline Doppler flow pattern. This was tested in 20 consecutive patients who were studied by pulse-wave Doppler echocardiography during cardiac catheterization. There was a close correlation between LVEDP and the change in A-wave velocity during the Valsalva maneuver (r = 0.85, SEE 6.7 mm Hg) regardless of the baseline E/A ratio. In patients with a LVEDP of <15 mm Hg the A wave decreased by 21 +/- 15 cm/s. In patients with a LVEDP of >25 mm Hg the A wave increased by 18 +/- 13 cm/s. The change in the E/A ratio during Valsalva correlated fairly with LVEDP (r = -0.72, SEE 8.8 mm Hg), the baseline E/A ratio correlated poorly, and scatter was substantial (r = 0.46, SEE 11.2 mm Hg). Just as elevated filling pressures can mask impaired relaxation, the impaired relaxation pattern can mask the presence of elevated filling pressures. This can be revealed by testing the response of the A wave to the Valsalva maneuver, allowing estimation of LVEDP independent of the baseline E/A ratio.

Left ventricular end-diastolic pressure can be estimated by either changes in transmitral inflow pattern during valsalva maneuver or analysis of pulmonary venous flow

We directly compared the transmitral inflow pattern during preload reduction and pulmonary venous flow velocities to determine left ventricular end-diastolic pressure (LVEDP) in 78 patients who underwent left heart catheterization. Transmitral inflow indexes (A-wave duration, ratio of peak flow velocity of early diastole [E] to peak flow velocity of late diastole during atrial contraction [A] [E/A ratio]) at rest and during the Valsalva maneuver (30 mm Hg for 15 seconds) and indexes of pulmonary venous flow (velocity and duration of the atrial reversal) were obtained. Fair correlations existed between LVEDP (mean 15+/-6 mm Hg) and the percentage decrease in the E/A ratio (r = 0.72), increase in duration of A wave during the Valsalva maneuver (r = 0.60), flow velocity of atrial reversal (r = 0.58), and difference of duration of atrial flow reversal and A wave (r = 0.62) (all P<.001). While sensitivity, specificity, and diagnostic accuracy to detect an elevated LVEDP were comparable, technically adequate Doppler recordings were obtained more often for the mitral inflow during the Valsalva maneuver than for the pulmonary venous flow (72 versus 66 patients, P< 0.05).

Alteration in left ventricular diastolic filling and accumulation of myocardial collagen at insulin-resistant prediabetic stage of a type II diabetic rat model

BACKGROUND

Considerable controversy exists regarding impairment of cardiac function in diabetes mellitus (DM). We investigated the serial changes in left ventricular (LV) histopathology and LV filling dynamics in Otsuka Long-Evans Tokushima Fatty (OLETF) rats, which have been established as an animal model of type II DM.

METHODS AND RESULTS

In 54 OLETF and 54 non-DM rats, body weight, blood pressure, heart rate, and transmitral pulsed Doppler examinations were performed from 5 to 47 weeks of age. An oral glucose tolerance test was performed at 10, 20, and 30 weeks of age. The hearts were excised for histopathology, including immunohistochemistry and histomorphometry of collagen, and measurement of hydroxyproline at baseline and each stage of developing DM. In the prediabetic stage (15 weeks of age), in which fast blood glucose remained normal, OLETF rats manifested mild obesity, postprandial hyperglycemia, and hyperinsulinemia, and early diastolic transmitral inflow exhibited prolonged deceleration time (OLETF, 59+/-10 ms versus non-DM, 49+/-8 ms, P<0.01) and low peak velocity (OLETF, 73+/-11 cm/s versus non-DM, 88+/-11 cm/s, P<0.01). Histopathology revealed extracellular fibrosis and abundant transforming growth factor-beta(1) receptor II in LV myocytes of OLETF rats. At 15 weeks of age, the ratio of collagen area/visual field of LV wall in OLETF rats (8.3+/-1.3%) was larger than that in non-DM rats (4.9+/-1.8%, P<0.0001), and the collagen content/dry tissue weight ratio of heart was significantly higher in OLETF (2. 0+/-0.5 mg/g) than non-DM (1.3+/-0.2 mg/g, P<0.01) rats.

CONCLUSIONS

A metabolic abnormality present in the prestage of type II DM may produce LV fibrosis and alteration in cardiac function.

Immunoglobulin adsorption in patients with idiopathic dilated cardiomyopathy

BACKGROUND

Idiopathic dilated cardiomyopathy (IDC) frequently is a progressive disease without causative therapy options. Following the hypothesis that in certain patients autoantibodies against cardiac structures may induce, maintain, or promote the progression of the disease, we investigated whether the elimination of these autoantibodies through immunoadsorption would improve cardiac function.

METHODS AND RESULTS

This prospective case-control study included 34 patients with IDC. Each patient presented with moderate to severe heart failure and evidence of autoantibodies directed against beta(1)-adrenoceptors (beta(1)-AABs). Seventeen patients received standard medical therapy (control group), whereas 17 were also treated with immunoadsorption (treatment group) to eliminate beta(1)-AABs. A 1-year follow-up included echocardiographic assessment of left ventricular ejection fraction and internal diameters, beta(1)-AAB levels, and clinical status every 3 months. Within 1 year, the mean+/-SD left ventricular ejection fraction rose from 22.3+/-3.3% to 37.9+/-7.9% (P=0.0001) in the treatment group, with a relative increase of 69.9%. However, in the control group, no overall increase was seen (from 23.8+/-3.0% to 25.2+/-5.9%, P=0. 3154). Left ventricular diameter in diastole decreased by 14.5% from 74.5+/-7.1 to 63.7+/-6.0 mm in the treatment group (P=0.0001) and by 3.8% (P=0.2342) in the control group. In the treatment group, the NYHA functional rating improved after immunoadsorption (P=0.0001). beta(1)-AABs did not increase anew.

CONCLUSIONS

In IDC, the use of immunoadsorption is superior to the use of standard medical therapy. It significantly improves cardiac performance and clinical status.

Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance

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