A simple, fast and reproducible echocardiographic approach to grade left ventricular diastolic function

Can echocardiographic assessment of diastolic function be automated?

Echocardiographic evaluation of left ventricular diastolic function relies on a multi-pronged algorithm, which incorporates Doppler-based and volumetric parameters. Integration of clinical data in diastolic assessment is recommended, though not clearly outlined. We sought to develop an automated tool for diastolic function, compare its performance to human-generated diagnoses and identify the common sources of error. Our software tool is based on the 2016 diastolic guidelines algorithm, which uses 8 parameters as input, with 10 conditions as the logic and 5 possible outputs as final diagnoses. Initially, we prospectively studied 563 patients whose diastolic function was independently evaluated by an expert echocardiographer and by the automated tool. Incongruent cases were further analyzed, after which features of myocardial disease were integrated into a refined version of the software that was tested in an independent cohort of 1106 patients. In the initial analysis, 202/563 grades (36%) were incongruent between the automated and human reads, with the highest rate of discordance for mild and indeterminate categories. In 17% of cases, human diagnoses differed from that dictated by the algorithm due to integration of clinical factors. Follow-up analysis using the refined automated tool did not improve the discordance rate (440/1106; 40%). There was more discordance in cases of: age > 40 years, impaired mitral inflow patterns (E/A < 0.8) and reduced mitral e' values. Further analysis revealed differences in how readers interpreted the interaction between these factors and diastolic function, which could not be incorporated into the automated tool. In conclusion, although assessment of diastolic function relies on an algorithm that can be automated, this algorithm does not include clear guidance on how to incorporate age, or age-related changes in Doppler-based parameters, often resulting in discordant diagnoses. Standardized interpretation of these factors is needed to improve the reproducibility of diastolic function grading by human readers and the accuracy of the automated classification.

LA reservoir strain: a sensitive parameter for estimating LV filling pressure in patients with preserved EF

An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction (HFpEF), and LV filling pressure is estimated with an algorithm in the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guideline. In this study, we sought to determine the efficacy of LA global longitudinal strain to estimate elevated LV filling pressure. Seventy-one consecutive patients (mean age of 63.2  ±  9.75, 70% male) who underwent left ventricular catheterization were included. Transthoracic echocardiography was performed within 24 h before catheterization. The LV filling pressure was estimated using echo parameters based on the 2016 ASE/EACVI algorithm. LA GLS was measured using 2D speckle tracking echocardiography in a four-chamber view (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and > 12 mm Hg was defined as elevated. Invasive LV filling pressure was defined as elevated in 41 (58%) and normal in 30 patients (42%). The LV filling pressure of 9 (13%) of 71 patients was defined as indeterminate based on the 2016 algorithm. Using the ROC method, 25.5% of LA reservoir strain (LASr) had a higher sensitivity (AUC = 0.79, specificity 77%, sensitivity 80%) in estimating LV filling pressure than the 2016 ASE/EACVI algorithm (AUC = 0.75, specificity 77%, sensitivity 70%). LASr, with higher sensitivity than 2016 ASE/EACVI algorithm, may be used as a single parameter to estimate LV filling pressure and hence may add incremental value toHFpEF diagnosis.

Relationship of left ventricular and atrial dimensions with moderate to severe left ventricular diastolic dysfunction (grade II and above)

Introduction

Left ventricular diastolic dysfunction (DD) is an entity in which the ventricle fails to fill up properly due to impaired ventricular relaxation and/or decreased compliance. The diagnosis of diastolic dysfunction is based on a variety of parameters in doppler echocardiograpy. However, some parameters like interventricular septal thickness in diastole (IVSd), posterior wall thickness in diastole (PWd), left ventricular internal end diastolic and systolic diameters (LVIDD and LVISD) along with left atrial diameters (LAD) have yet to be evaluated for the diagnostic workup of DD.

Methods

A case control study was done in the cardiology department from patient records from 2016 to 2018. Patients were diagnosed as diastolic dysfunction grade II and above by doppler echocardiography. IVSd, PWd, LVIDD, LAD, LVISD were obtained through 2-D echocardiography.

Results

Patients with DD had greater LAD, IVSd and PWd and decreased LVIDD and LVISD as compared to control group. Overall, IVSD was the most significant predictor (OR 1.52 95%CI 1.35–1.71) of DD followed by PWd and LAD. Similarly, LAD, IVSd and PWd had higher sensitivity and specificity than LVIDD and LVIDS.

Conclusion

IVSd, LAD and PWd showed significant performance in the diagnosis of diastolic dysfunction and hence can be used as a screening and diagnostic tool in diastolic dysfunction of grade ll and above.

A simplified definition of diastolic function in sepsis, compared against standard definitions

Background

Guidelines for grading diastolic dysfunction poorly categorize septic patients. We compared how well the American Society of Echocardiography (ASE) 2009 and 2016 definitions and a simplified definition categorized septic patients.

Methods

We studied septic patients who received a transthoracic echocardiogram within 24 h of admission to an ICU. We categorized patients according to ASE 2009 and 2016 definitions and a definition using E/e’, a surrogate for left ventricular filling pressure. We assessed 28-day all-cause mortality and the presence of pre-existing diabetes, hypertension, or myocardial infarction. We tested for associations among diastolic grade, comorbidities, and outcomes using logistic regression.

Results

We studied 398 patients. Mortality was 23%. The simplified definition categorized more patients than ASE 2016 (78% vs. 71%, p = 0.035); both definitions categorized more patients than ASE 2009 (34%, p < 0.001 for both comparisons). Higher grades of diastolic dysfunction were associated with hypertension (ASE 2016, simplified), myocardial infarction (ASE 2009, simplified), and diabetes (simplified). Grade of diastolic dysfunction was not associated with mortality by any definition. Of 199 patients categorized as normal by ASE 2016, 40% had an abnormal E/e′ > 9 and 7% had a severely abnormal E/e′ > 13.

Conclusions

The ASE 2016 definition categorizes more septic patients than the ASE 2009 definition, but it does not categorize the diastolic function of a third of septic patients. ASE 2016 designates many patients with elevated E/e′ as normal. A simplified definition categorized patients with less ambiguity and is associated with relevant comorbidities.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0367-3) contains supplementary material, which is available to authorized users.

Some Morpho-Functional Changes of the Left Heart in Patients with Viral Liver Cirrhosis

Material and methods. 55 patients with VLC class А, B, C according to Сhild-Pugh were examined. The average age of patients 42 years, disease duration – 3,8 years. Depending on the presence of ascites, patients were divided into 2 groups: 28 patients had no ascites (group 1), 27 patients had ascites (group 2), and a control group of 22 healthy people. Echocardiography was performed by the "VIVID E 95" device. All patients were evaluated diastolic function of the LV in accordance with the АSЕ/ЕAЕ-2009 and ASE/EACVI-2016 recommendations. Holter monitoring of ECG was performed. Statistical data processing was carried out using Statistica 6.0 statistical software package and Mann-Whitney nonparametric test. The correlation analysis was performed using the Spearman coefficient.

Results. In all patients there was an increase in the index of myocardial mass and relative wall thickness of LV in comparison with the control group, more severe disorders were identified in patients with VLC with ascites, p<0.001. In the study of LV remodeling, concentric hypertrophy was most common in patients with VLC – in 11 (43%) patients of the 1st group and in 19 (70%) patients of the 2nd group. Holter monitoring of ECG revealed supraventricular extrasystoles in 9 (32%) patients of the 1st group and 11 (40%) – 2nd group; paroxysmal form of atrial fibrillation – in 2 (7%) patients and in 5 (18%), respectively. It was found that the maximum index of the left atrial volume was higher in patients with VLC compared to control, and in patients with ascites this disorder was more pronounced (p<0.001). In accordance with the ASE/EACVI-2016 algorithm, normal diastolic LV function was registered almost twice as often as when using the ASE/EAE-2009 algorithm. Undefined result was recorded in 8% of cases due to tricuspid regurgitation.

Conclusion. Thus, patients with VLC develop an increase in the LV myocardial mass with the formation of concentric hypertrophy, remodeling of the left atrium with the occurrence of cardiac arrhythmias, diastolic LV dysfunction, and these changes are more pronounced in patients with ascites. In accordance with the new algorithm ASE/EACVI-2016 for detection of diastolic LV dysfunction, normal LV diastolic function was almost 2 times more common in patients with VLC than in accordance with the old ASE/EAE-2009 algorithm.

Cardiovascular predictors of death in patients with cirrhosis

Cirrhotic cardiomyopathy is associated with poor outcomes in patients with cirrhosis. We investigated if subclinical cardiac morphologic and functional modifications can influence survival in patients with cirrhosis during follow-up. A series of patients with cirrhosis without cardiovascular or pulmonary disease underwent standard and tissue Doppler echocardiography to assess left ventricular geometry, systolic/diastolic function, and the main haemodynamic parameters. After baseline evaluation 115 patients with cirrhosis were followed up for at least 6 years. During follow-up 54 patients died (47%). On univariate analysis, age, body surface area (BSA), Model for End-Stage Liver Disease (MELD), mean arterial pressure, heart rate, cardiac index, systemic vascular resistance index, and the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/è) were associated with increased risk of death. In a Cox hazard regression analysis including these factors and other hypothesized important factors (but not MELD), increased age (P = 0.04) and left atrial dimension (P = 0.005) and lower BSA (P = 0.03) were the strongest predictors of death. When MELD was included in the analysis, the main predictors were MELD, age, and BSA. When multivariate analysis was performed incorporating only cardiovascular parameters, increased E/è (P = 0.003) and heart rate (P = 0.03) and reduced mean blood pressure (P = 0.01) were significantly associated with poor prognosis.

CONCLUSION

In a large cohort of patients with cirrhosis and after a long follow-up, MELD, age, and BSA were the main predictors of death; among cardiovascular parameters, left atrium enlargement, increased heart rate and E/è, and reduced mean blood pressure were independent predictors of death. (Hepatology 2018).

Early detection of left ventricular diastolic dysfunction using conventional and speckle tracking echocardiography in a large animal model of metabolic dysfunction

Left ventricular (LV) diastolic dysfunction is one of the important mechanisms responsible for symptoms in patients with heart failure. The aim of the current study was to identify parameters that may be used to detect early signs of LV diastolic dysfunction in diabetic pigs on a high fat diet, using conventional and speckle tracking echocardiography. The study population consisted of 16 healthy Göttingen minipigs and 18 minipigs with experimentally induced metabolic dysfunction. Echocardiography measurements were performed at baseline and 3-month follow-up. The ratio of peak early (E) and late filling velocity (E/A ratio) and the ratio of E and the velocity of the mitral annulus early diastolic wave (E/Em ratio) did not change significantly in both groups. Peak untwisting velocity decreased in the metabolic dysfunction group (- 30.1 ± 18.5 vs. - 23.4 ± 15.5 °/ms) but not in controls (- 38.1 ± 23.6 vs. - 42.2 ± 23.0 °/ms), being significantly different between the groups at the 3-month time point (p < 0.05). In conclusion, whereas E/A ratio and E/Em ratio did not change significantly after 3 months of metabolic dysfunction, peak untwisting velocity was significantly decreased. Hence, peak untwisting velocity may serve as an important marker to detect early changes of LV diastolic dysfunction.

Cardiac Shear Wave Velocity Detection in the Porcine Heart

Cardiac muscle stiffness can potentially be estimated non-invasively with shear wave elastography. Shear waves are present on the septal wall after mitral and aortic valve closure, thus providing an opportunity to assess stiffness in early systole and early diastole. We report on the shear wave recordings of 22 minipigs with high-frame-rate echocardiography. The waves were captured with 4000 frames/s using a programmable commercial ultrasound machine. The wave pattern was extracted from the data through a local tissue velocity estimator based on one-lag autocorrelation. The wave propagation velocity was determined with a normalized Radon transform, resulting in median wave propagation velocities of 2.2 m/s after mitral valve closure and 4.2 m/s after aortic valve closure. Overall the velocities ranged between 0.8 and 6.3 m/s in a 95% confidence interval. By dispersion analysis we found that the propagation velocity only mildly increased with shear wave frequency.