Comparison of pulsed Doppler echocardiography and radionuclide angiography in the assessment of left ventricular filling

[Left ventricular diastolic dysfunction in young people with type 1 diabetes mellitus. Associated factors]

AIM

The aim of our study was to evaluate left ventricular function of diastolic in young (< 40 years) asymptomatic patients with type 1 diabetes mellitus free of cardiovascular disease symptoms and to analyze the associated factors to the left ventricular diastolic dysfunction (LVDD) in these patients.

PATIENTS AND METHODS

Thirty-five type-1 diabetic patients (mean age 27.8+/-7.5 years) old and 54 healthy controls (mean age 26.1+/-4.1 years) were studied. Anamnesis, physical exploration, general analytical studies, microalbuminuric and Doppler-echocardiographic studies were performed.

RESULTS

The LVDD was present in 13 (37.1%) of the diabetic patients and none of the control patients. The ratio of peak early to peak late (atrial) filling velocity was significantly decreased in diabetic compared with control subjects (1.1+/-0.3 versus 1.5+/-0.2; p<0.01). The isovolumetric relaxation time was increased in diabetic patients compared with control subjects (104+/-11 versus 79+/-11; p<0.01). Diabetics with LVDD were older aged, predominantly males, had worse glucemic control, more alteration of lipidic metabolism and higher levels of microalbuminuria, than diabetics without LVDD.

CONCLUSIONS

The LVDD is frequent in young diabetics free of cardiovascular disease symptoms. These studies suggest that because this patients were of older age, of the masculine sex with, poor glucemic control, altered lipidic metabolism, and microalbuminuria they might be a group that is associated with LVDD which, in the absence of cardiovascular disease, might be an early preclinical alteration, potentially related to subsequent development of diabetic cardiomyopathy.

The effect of respiration on left ventricular diastolic filling as assessed by radionuclide ventriculography

Left ventricular function is modified by respiration and pericardial constraint. The aim of this study was to compare left ventricular systolic and diastolic function during inspiration and expiration in four patient groups: patients (1) without cardiac disease, (2) with severe pulmonary disease, (3) with cardiac amyloid and (4) with pericardial constriction (before and after pericardiectomy). Using blood-pool left ventriculography with modified gating, we obtained time-activity curves at the onset of inspiration and expiration. On inspiration and expiration, patients with pericardial constriction and patients with cardiac amyloid were significantly different from those without cardiac disease and those with severe pulmonary disease, in that left ventricular ejection fraction (LVEF) was less, peak filling rate was greater, time to peak filling rate was shorter, and rapid filling fraction was increased. When inspiration and expiration were compared, time to left ventricular peak filling rate was shorter (P = 0.05) on inspiration (118 +/- 48 ms) than on expiration (168 +/- 35 ms) in patients with pericardial constriction. No other measures differed between inspiration and expiration in pericardial constriction, and left ventricular function was unaffected by respiration in the other groups. Time to left ventricular peak filling rate was 49 +/- 69 ms less on inspiration than on expiration in pericardial constriction and this difference was significantly different (P = 0.04) from that in patients with cardiac amyloid (34 +/- 58 ms greater), patients without cardiac disease (2 +/- 69 ms greater) and patients with severe pulmonary disease (19 +/- 63 ms less). In pericardial constriction, pericardial resection caused an increase in LVEF without a change in left ventricular diastolic filling but abolished the differences present between inspiration and expiration in time to left ventricular peak filling rate. This respiratory response in time to left ventricular peak filling rate may be valuable in the diagnosis of pericardial constriction.

Significance of prominent atrial-wave and diastasis deflection in radionuclide diastolic volume curve during exercise in detection of coronary artery disease

BACKGROUND

Exercise testing with multigated acquisition technetium radionuclide cineangiography (MUGA) is a useful modality that can discriminate systolic and diastolic performance in patients with ischemic heart disease. However, some patients may have abnormal left ventricular filling dynamics with normal regional and global systolic function.

HYPOTHESIS

The purpose of the study was to assess exercise-induced diastolic dysfunction as expressed by a prominent atrial (A) wave or diastasis deflection at the left ventricular volume curve, in patients with different degrees of ischemic heart disease.

METHODS

In all, 32 men and 7 women aged 35-70 years (mean 54 +/- 8.6 years) underwent MUGA at rest and during exercise for analysis of the radionuclide volume curve. Within 6 weeks, thallium-201 scintigraphy and coronary angiography were performed and the patients were categorized into three groups: (1) disease-free (n = 10), (2) single-vessel disease (> 50% stenosis) (n = 19), and (3) double-vessel disease or more (n = 10). A waves or diastasis deflections were compared among the groups.

RESULTS

Significant differences (p < 0.01) were noted in A-wave deflection relative to peak diastolic volume curve during exercise (Aexe/T) between Group 1 and Groups 2 and 3. Group 1 manifested only a mild rise in A-wave deflection from rest (20.20 +/- 8.49%) to exercise (25.85 +/- 8.49%), whereas Groups 2 and 3 exhibited a significant increase from 25.89 +/- 9.55% and 28.40 +/- 12.6%, respectively, to 60.21 +/- 22.5% and 63.0 +/- 22.86%, respectively. Group 2 had a significantly (p < 0.05) higher maximal heart rate than Group 3.

CONCLUSIONS

The addition of prominent A-wave or diastasis deflection to a normal systolic response during exercise testing with multigated radionuclide cineangiography might be a sensitive marker of coronary artery disease. The A wave represents diastolic dysfunction of the left ventricle, considered an early event in the ischemic cascade.

An audit of echocardiograms in acute left ventricular failure

All patients with heart failure should have an echocardiogram to establish a diagnosis, both to aid treatment as well as for prognostic reasons. An audit of 100 case notes of patients admitted with acute left ventricular failure over a 12-month period found that 26 patients had not had an echocardiogram. Of the 74 who did have an echocardiogram 68 patients had reduced systolic function (mean ejection fraction 42%). Almost all (93%) were commenced on an angiotension-converting enzyme (ACE) inhibitor. Those who did not receive an ACE inhibitor had no contraindications to these drugs. Seventeen patients had a confirmed myocardial infarction. Of these, 11 had an echocardiogram and 10 were discharged home on an ACE inhibitor. Despite appropriate indications some patients are deprived of echocardiography as well as the benefits of ACE inhibitors.

Comparison between transesophageal Doppler echocardiography and nuclear cardioangiography for the evaluation of left ventricular filling during coronary artery bypass grafting

This study examines the relative contribution of early (E) and atrial (A) filling of the left ventricle. Ten patients were studied under anesthesia before and after coronary artery bypass grafting (CABG) using measurements of the mitral velocity-time integral (VTI) with transesophageal pulsed Doppler echocardiography and nuclear angiocardiography simultaneously. Thermodilution cardiac output measurements were made simultaneously in order to express the E and A filling in quantitative terms. The mean difference between methods in estimating E filling was -1.0 mL and the figures for the mean +/- 2 SD were 5.7 and -7.8 mL, r = 0.98 using regression analysis. The mean difference during A filling was 0.9 mL and the corresponding figures for the mean +/- 2 SD were 7.9 and -6.1 mL, r = 0.88. There was a reduction in the volume entering the left ventricle during the E filling (42-26 mL) and in the A phase (27-22 mL) from before surgery in comparison to after CABG. There was good agreement between transesophageal Doppler echocardiographic and nuclear angiocardiographic methods concerning the volume contribution during E and A phases of left ventricular filling.

Left ventricular diastolic filling during coronary artery bypass surgery in patients with diabetes mellitus and/or hypertension

To evaluate left ventricular diastolic filling (DF) using transesophageal Doppler echocardiography in 40 patients with or without diabetes mellitus and/or hypertension, we measured DF after induction of anesthesia, before and after cardiopulmonary bypass (CPB), and at the end of coronary artery bypass surgery (CABS). In 13 patients with complete measurements, there was no significant change in DF but diastolic filling time became shorter and peak velocity during atrial contraction increased significantly following CPB. In the other patients, the assessment of DF could be performed accurately in CABS patients without diabetes and/or hypertension, but not in CABS patients with these disorders because of a high incidence of fusion of the E-A waves, which is an indicator of impaired DF. When heart rate (HR) was more than 75 beats·min^-1 (RR interval of less than 800 ms), the incidence of fusion points was significantly higher in patients with diabetes and/or hypertension than without (13 of 29s 1 of 9,P<0.05). It is suggested that a slower HR (less than 75 beat·min^-1) is desirable in CABS patients with these disorders to avoid impairment of DF due to either prolonged systolic time or isovolumic relaxation time.

Age-dependent influence of heart rate on Doppler indexes of left ventricular filling

BACKGROUND AND OBJECTIVE

The Doppler indexes of left ventricular filling are related to age and heart rate. The aim of this study was to assess whether the influences of heart rate and age interactions (that is, whether the effect of heart rate on the Doppler indexes) is modified by age.

SUBJECTS AND METHODS

The effects of atropine-induced heart rate increases on the transmitral velocities were compared in 10 younger healthy subjects aged 26-38 years and 12 older healthy subjects aged 50-67 years.

RESULTS

With a comparable total rise in heart rate (on average 20 beats min-1), the peak early diastolic velocity decreased likewise in both groups (from 66 +/- 9 to 57 +/- 9 cm s-1 in the younger age group and from 58 +/- 15 to 47 +/- 13 cm s-1 in the older age group). The peak atrial velocity remained unaltered in the older group (53 +/- 16 vs. 52 +/- 14 cm s-1) but rose from 33 +/- 6 to 44 +/- 12 cm s-1 in the younger (P = 0.02). The early-to-atrial peak velocity ratio decreased from 1.2 +/- 0.6 to 1.0 +/- 0.4 cm s-1 in the older subjects and from 2.0 +/- 0.5 to 1.4 +/- 0.5 cm s-1 in the younger subjects (P = 0.01). Changes in the other Doppler indexes were similar in both groups.

CONCLUSIONS

The effect of heart rate on certain Doppler indexes of left ventricular filling is age-dependent. The peak velocity ratio cannot be interpreted without adjusting for heart rate in younger subjects, whilst in older people heart rate variation is of less importance.

Doppler echocardiographic evaluation of the spectrum of left ventricular diastolic dysfunction in essential hypertension

Left ventricular topography and diastolic and systolic functions were studied in 41 patients with essential hypertension (group 1) and 33 age-matched normal adults (group 2) by Doppler echocardiography. In group 1 54% had LV concentric hypertrophy, 19% had combined concentric hypertrophy and eccentric remodeling, and 27% had concentric remodeling. LV systolic function was within the normal range. In concentric LV remodeling, the EDV was significantly decreased (compared with group 2) (84 +/- 15 vs 130 +/- 38 ml, p < 0.05), whereas the NPFR was normal (2.89 +/- 0.65 vs 3.22 +/- 0.83 sec-1, p = NS). In concentric hypertrophy, LV end-diastolic and end-systolic volumes were normal, but the NPFR was decreased (2.04 +/- 0.59 sec-1). Patients with concentric hypertrophy and eccentric remodeling had the largest end-diastolic (140 +/- 48 ml) and end-systolic (62 +/- 32 ml) volumes and the lowest NPFR (1.67 +/- 0.69 sec-1). The LVMI inversely correlated with the NPFR (r = -0.89, p < 0.0001). Thus LV concentric hypertrophy with or without concentric or eccentric remodeling is seen in patients with systemic hypertension. A decrease in peak filling occurs early in the evolution of hypertensive heart disease and is observed even when systolic performance is still normal.

Two-dimensional transesophageal echocardiographic characterization of ventricular filling in real time by acoustic quantification: comparison with pulsed Doppler echocardiography

Little is known about the accuracy of acoustic quantification (AQ) in the assessment of left ventricular diastolic filling. Therefore the objective of this study was to determine the ability of AQ applied to two-dimensional echocardiography to characterize left ventricular diastolic filling compared with Doppler echocardiography. In 80 unselected patients, AQ of left ventricular diastolic filling was performed during two-dimensional transesophageal echocardiography. Pulsed Doppler transthoracic echocardiography was performed at the tips of the mitral valve leaflet and the mitral annulus level. In 53 patients with synchronous systolic wall motion, significant correlations were found between AQ-derived versus Doppler-derived indexes obtained from the level of the mitral annulus of peak rate of increase in left ventricular diastolic area versus peak early filling velocity (r = 0.78; p < 0.0001), peak early/peak atrial rate of change in left ventricular area ratio versus peak early/peak atrial filling velocity ratio (r = 0.80; p < 0.0001), and percent atrial contributions to filling (r = 0.80; p < 0.0001). Correlations between acceleration time and deceleration time derived by AQ versus Doppler echocardiography were poor. Acoustic quantification-derived acceleration and deceleration times significantly underestimated analogous times derived by Doppler echocardiography at the mitral annulus level. Correlations obtained between AQ-derived indexes and Doppler echocardiography were better with pulsed Doppler performed at the mitral annulus level compared with the leaflet tips. In 27 patients with asynchronous systolic wall motion, the correlations between AQ-derived indexes and Doppler-derived indexes of the relative distribution of filling were similar to those of the group of subjects with synchronous wall motion. However, in patients with asynchronous wall motion the correlations between indexes of peak early filling velocity and rate worsened. In addition, no correlations were found between acceleration and deceleration times derived by the two techniques in subjects with asynchronous systolic wall motion. Acoustic quantification assessment of left ventricular diastolic filling accurately characterizes the distribution of diastolic filling compared with Doppler echocardiography. The presence of asynchronous systolic wall motion decreases the accuracy of the AQ method in assessing peak filling rate. The ultimate clinical application of AQ in the assessment of left ventricular diastolic filling is yet to be determined but appears promising.

Mitral valve calcification as an index of left ventricular dysfunction in patients with end-stage renal disease on peritoneal dialysis

OBJECTIVE

To determine whether mitral valve or anulus calcification (MC) in patients with end-stage renal disease is associated with abnormalities of left ventricular (LV) structure and function, cardiac characteristics of 55 patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with (n = 26; age: 59 +/- 10 years) vs without (n = 29; age: 58 +/- 12 years) MC were analyzed using echocardiography and Doppler echocardiography. Sclerosis of the mitral valve anulus was detected in 18 (7 women, 11 men; age: 58 +/- 10 years) patients, sclerosis of mitral valve leaflets in 24 (13 women, 9 men; age: 59 +/- 10 years) patients. Patients with MC had higher systolic arterial blood pressure before initiation of dialysis therapy (191/104 mm Hg vs 173/94 mm Hg; p < 0.05) and higher calcium-phosphorus products (55 +/- 13 vs 42 +/- 16; p < 0.05) during CAPD therapy than those without MC. Neither prevalence nor severity of MC was related to dialysis duration or patient age. Systolic LV function was reduced (ejection fraction: 58 +/- 12 percent vs 65 +/- 13 percent; p < 0.05) and LV end-diastolic diameters were dilated (54 +/- 5 vs 50 +/- 8 mm; p < 0.05) in patients with MC. Left atrial dilatation (73 percent vs 31 percent; p < 0.005) and mitral valve regurgitation (65 percent vs 21 percent; p < 0.001) were more frequent in patients with vs those without MC. Excluding patients with significant mitral regurgitation from pulsed Doppler analysis, diastolic LV function was comparably impaired in patients with vs those without MC (maximal early/atrial filling velocity ratio: 0.77 +/- 0.25 vs 0.75 +/- 0.22; atrial filling fraction: 47 +/- 10 percent vs 48 +/- 11 percent; p = NS). The presented data suggest that MC follows long-standing and severe arterial hypertension before start of dialysis therapy. Therefore, effective blood pressure control in the predialysis period may be a tool to prevent these lesions. MC has clinical significance as a marker of LV dilatation and reduced LV systolic function in patients with chronic CAPD.

Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy during a one-year follow-up: relation to the clinical course of disease

In idiopathic dilated cardiomyopathy (IDC), an impaired left ventricular filling as assessed by the Doppler echocardiographic mitral flow pattern is closely related to the severity of congestive heart failure. This study examined the relation of left ventricular filling and the clinical course of the disease in patients with a recent diagnostic procedure and initiation of medical therapy (group 1, n = 15) as compared with patients in a chronic stage of the disease (group 2, n = 24) with the diagnosis established > 1 year before. All patients had to be in sinus rhythm to facilitate the Doppler echocardiographic evaluation of left ventricular filling. The clinical status was assessed by the New York Heart Association classification and a heart failure score at baseline and after a period of 12 +/- 7 months. At baseline the ratio of the peak early/atrial Doppler velocities (VE/VA) was shifted toward the early diastole in group 1 as compared to group 2 (1.84 +/- 1.02 vs 1.12 +/- 0.55; p < 0.05). Symptoms of heart failure were more severe in group 1. During follow-up, VE/VA tended to decrease in group 1 from 1.84 +/- 1.02 to 1.35 +/- 1.03 (p = 0.07) and remained unchanged in group 2 (1.12 +/- 0.55 and 1.34 +/- 1.23; not significant). In a subgroup of 10 patients who underwent repeat right heart catheterization, the decrease of VE/VA coincided with a decrease of the pulmonary capillary wedge pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired left ventricular filling in borderline hypertensive patients without cardiac structural changes

To determine the effect of borderline hypertension on left ventricular diastolic performance, 16 patients with borderline hypertension who did not have left ventricular hypertrophy and 16 age-sex-matched patients with normotension of similar age and body mass index were investigated. Pulsed Doppler echocardiography was used to record left ventricular filling signals at rest and immediately after supine ergometer exercise. All subjects had normal left ventricular structure and systolic function. At rest the borderline hypertension group in comparison with the normotension group had a depressed peak velocity of early filling (E) (44 +/- 7 vs 54 +/- 10 cm/sec; p < 0.01), no enhanced peak velocity of late filling (A) (52 +/- 8 vs 50 +/- 11 cm/sec; not significant), and a reduced E/A ratio (0.9 +/- 0.2 vs 1.1 +/- 0.3; p < 0.05). Atrial filling time and preejection period were similar in the two groups. The effect of exercise on left ventricular filling velocity in patients with borderline hypertensive resembled that in those with normotension. Percentage changes in E (+14% +/- 12% vs +14% +/- 13%) and A (+13% +/- 8% vs 11% +/- 12%) were equivalent, suggesting a preserved diastolic reserve for exercise in the borderline hypertension group. In conclusion, borderline hypertension appears to be predictive of early filling impairment, and a late filling compensative mechanism is not yet apparent. These findings in borderline hypertension without apparent cardiac damage call for clinical attention to prevent further deterioration in cardiac function.

Diastolic left ventricular function after renal transplantation in patients with normal and hypertrophied myocardium

While diastolic left ventricular (LV) dysfunction is frequent and associated with cardiovascular complications in end-stage renal disease treated with dialysis, controversial information exists on diastolic LV function after renal transplantation. Therefore, Doppler echocardiographic parameters of LV diastolic filling were analyzed in 17 transplanted patients with normal LV mass (< 150 g/m2; mean: 128 +/- 17 g/m2) and 24 transplanted patients with LV hypertrophy (> 150 g/m2; mean: 197 +/- 36 g/m2) and compared with 28 normal controls without and 11 controls with LV hypertrophy. Mean age (normal vs. increased LV mass: 46 +/- 13 vs. 48 +/- 11 years; p = NS) and transplantation duration (60 +/- 35 vs. 50 +/- 37 months; p = NS) were comparable between renal patients, while systolic blood pressure (136 +/- 12 vs. 149 +/- 14 mmHg; p < 0.02) and serum creatinine (1.55 +/- 0.45 vs. 1.98 +/- 0.76 mg/dl; p < 0.05) were higher in patients with than without LV hypertrophy. In transplanted patients with LV hypertrophy, peak early/atrial filling velocity ratios were decreased (1.17 +/- 0.34 vs. 0.94 +/- 0.34; p < 0.05), mean atrial filling fractions were increased (37 +/- 7% vs. 42 +/- 7%; p < 0.05), and isovolumic relaxation periods were prolonged (86 +/- 23 vs. 106 +/- 26 ms; p < 0.02) compared with transplanted patients with normal LV mass. The frequency of pathologic peak early/atrial filling velocity ratios (12 vs. 42%; p < 0.05), atrial filling fractions (12 vs. 25%; p = NS) and isovolumic relaxation periods (6 vs. 29%; p = NS) was higher in transplanted patients with than without LV hypertrophy. Individual ratios of peak early/atrial filling velocity were inversely correlated with age in transplanted patients with normal LV mass (p < 0.002), and atrial filling fractions were correlated with LV mass index in transplanted patients with LV hypertrophy (p < 0.01). Diastolic LV function was comparable in both groups of transplanted patients with their corresponding non-renal controls. It is concluded that, in transplanted patients, diastolic LV filling is comparable to nonrenal controls; it is age-dependent in patients with normal LV mass and mass-dependent in those with LV hypertrophy.

Impact of hemodialysis on left and right ventricular Doppler diastolic filling indices

Hemodialysis is associated with acute reduction in intravascular volume. To assess the impact of volume reduction on left and right ventricular diastolic filling indexes obtained by Doppler echocardiography, 24 patients on chronic hemodialysis were consecutively studied before, during, and immediately after one hemodialysis session. Twenty four normal sex and age-matched volunteers served as a control group. Study patients had abnormal diastolic indexes when compared to controls. At 2 hours of dialysis (mid dialysis) there was a significant decrease in peak early mitral flow velocity (E), no change in peak atrial filling velocity (A), and a reduction in the E/A ratio. The deceleration time of the mitral E wave also was prolonged compared to baseline. Similar findings were observed with respect to right ventricular filling indices. These changes occurred during the first 2 hours of dialysis and remained unaltered at end dialysis. When patients were subdivided according to weight loss, only the group that lost 1 or more kilograms had significant changes in the Doppler parameters of the left and right ventricle, as well as reduction of the left ventricular dimensions. These findings suggest that preload reduction is the main mechanism that accounts for acute changes in Doppler diastolic indices observed during hemodialysis.

The role of Doppler echocardiography in the assessment of left ventricular diastolic function

The role of Doppler echocardiography of transmitral filling velocities in the assessment of diastolic function in man has not been adequately defined. It is now appreciated that multiple interacting factors such as loading conditions influence the transmitral velocity profile independent of intrinsic left ventricular diastolic function. Extrapolating the status of diastolic function from the transmitral velocity profile is complicated by these factors. The load dependence of ventricular filling has tempered the initial enthusiasm for the clinical application of the Doppler technique. In the present review, studies examining invasive parameters of diastolic function and Doppler indices of diastolic filling are discussed to gain greater insight and understanding of the role of Doppler echocardiography in the noninvasive assessment of diastolic function. These studies have demonstrated a relatively consistent influence of left ventricular relaxation, chamber stiffness, and left atrial pressure on the transmitral velocity filling profile. Impairment of relaxation impedes early filling and may result in a compensatory increase in atrial contribution to filling. An independent decrease in left atrial pressure from altered loading conditions may also reduce filling in early diastole. Increased left ventricular chamber stiffness (i.e., noncompliant left ventricle) impairs atrial contribution to filling and may enhance early filling. Theoretically, reduced left atrial contractility may decrease atrial contribution to filling. Pulmonic vein flow demonstrating increased retrograde flow during atrial systole helps to exclude impaired left atrial contractility. An increased left atrial pressure from altered loading conditions may also augment early filling. Therefore, an invasive or clinical assessment of left atrial pressure as being increased, decreased, or normal greatly aids in the interpretation of the transmitral filling velocity profile when inferences on the status of diastolic function are being made. Diastolic dysfunction is likely when a given pattern of filling cannot be explained on the basis of left atrial pressure. In situations where reasonable estimates on the status of left atrial pressure cannot be done, striking alterations in the transmitral velocity filling profile may be useful.

The radionuclide assessment of left ventricular diastolic filling: methodology and clinical significance

The radionuclide measurement of diastolic performance may provide a rapid noninvasive index available in the clinical setting. These measurements may be used to detect coronary artery disease, manifestations of hypertensive heart disease, isolated diastolic heart failure, and hypertrophic cardiomyopathy. The various radionuclide methods to measure diastolic filling are influenced by technological considerations, as well as applying the results in the appropriate clinical context. The importance of these derived measurements and how they correspond to various pathophysiological presentations will be discussed.

Factors influencing transmitral flow velocity in normal and hypertensive subjects

Transmitral flow velocity and its determinants were examined with Doppler echocardiography in 53 hypertensive and 32 age-matched healthy normotensive men. Early and late maximal transmitral velocity, and early and late flow velocity integral were evaluated. In comparison with normal subjects, hypertensive patients were characterized by decreased maximal early velocity (66.3 +/- 12.3 versus 72.3 +/- 11.5 cm/sec, p less than 0.05), normalized early flow integral (67 +/- 7% versus 73 +/- 5%, p less than 0.001), increased maximal late flow velocity (45 +/- 10 cm/sec, p less than 0.001), and normalized late flow integral (29 +/- 7% versus 21 +/- 5%, p less than 0.001). Abnormally high late transmitral flow was found in 47% of the hypertensive group. Multiple regression analysis revealed that in normal subjects transmitral flow indexes were determined by age, relative wall thickness, and systolic blood pressure, but not by heart rate. A strong relationship of Doppler transmitral flow indexes with age was confirmed in hypertensive patients; however, relative wall thickness influenced transmitral flow velocity only weakly and systolic blood pressure did not affect transmitral flow. Left ventricular mass and diastolic blood pressure did not influence mitral filling velocity in either group. The altered pattern of mitral inflow found in a large number of hypertensive subjects is not related to elevated arterial blood pressure or to altered left ventricular geometry.

The spectrum of left ventricular filling in severe aortic stenosis

To assess left ventricular diastolic filling in valvular aortic stenosis, pulsed Doppler echocardiography was used prospectively in 35 patients with severe aortic stenosis (valve area less than 1 cm2) and in 38 age-matched normal subjects. Twenty-seven patients had a normal left ventricular systolic function at rest (ejection fraction greater than 0.50) and a normal or only slightly increased mean pulmonary capillary wedge pressure (mean 11 +/- 4 mm Hg). Eight patients had a poor left ventricular systolic function (ejection fraction: 0.28 +/- 0.10) and an elevated mean pulmonary capillary wedge pressure (mean: 36 +/- 9 mm Hg). The Doppler derived filling parameters were correlated with hemodynamic data, left ventricular wall thickness derived from M-mode echocardiograms, heart rate and atrio-ventricular (A-V) conduction delay using stepwise multiple correlation. The data of this study suggest that left ventricular filling is significantly impaired in patients with severe aortic stenosis and left ventricular hypertrophy with an increase in late diastolic (A-wave) velocity, an increase in the A/E ratio, a decrease in the first one-half filling fraction and a prolongation of early diastolic deceleration time. These changes in filling hemodynamics are associated with alterations in mean pulmonary capillary wedge pressure, left ventricular wall thickness, heart rate and A-V conduction delay. When heart failure develops as a result of impaired left ventricular systolic function, an increase in left atrial filling pressure is associated with a shift of left ventricular filling towards early diastole with a 'normalisation' of the transmitral flow velocity curve. In extreme cases, a progression towards a 'restrictive' filling pattern is found with a marked shortening of the left ventricular early diastolic deceleration time. In the presence of high filling pressures, increased left atrial driving pressure (derived from the mean pulmonary capillary wedge pressure) is associated with changes in the left ventricular filling pattern irrespective of the presence and the degree of myocardial hypertrophy.

Diastolic ventricular function in type 1 diabetic patients: a study using Doppler echocardiography

The transmitral flow velocity pattern of 28 Type 1 diabetic patients and 39 age-matched healthy control subjects was studied for determination of left ventricular diastolic function. No patient had systemic hypertension, congestive heart failure, or ischaemic heart disease by clinical or electrocardiographic criteria. Echocardiographic measures of systolic ventricular function were within normal range in all subjects. The ratio of early to late transmitral peak flow velocity (ve/va) was significantly decreased in the diabetic patients (1.3 +/- 0.1 (+/- SE) vs 1.6 +/- 0.1, p less than 0.05), while other Doppler derived variables did not show any significant difference. No correlation of ve/va with duration of diabetes was found (r = -0.27), but it correlated with age in both groups (both r = -0.40, p less than 0.05). Furthermore, a significant correlation was found between ve/va and heart rate (r = -0.55 for diabetic patients, p less than 0.01; r = -0.58 for control subjects, p less than 0.01). After matching for heart rate (24 diabetic patients and 24 control subjects) no significant decrease of ve/va was observed in the diabetic group.

Left ventricular muscle mass and diastolic function in patients with essential hypertension under long-term clonidine monotherapy

To determine whether alterations of left ventricular (LV) structure are associated with improved LV function under chronic clonidine monotherapy (300-450 g/day) of essential hypertension, 11 male patients (age range 47-61 years) were followed for 5.4 +/- 0.9 months using echocardiography and Doppler echocardiography. Blood pressure decreased from a mean of 168/105 to 150/96 mmHg (p less than 0.01), heart rate remained unchanged (73 +/- 10 vs. 71 +/- 10 beats/min). LV muscle mass decreased from 350 +/- 73 to 297 +/- 56 g (p less than 0.02), LV volume/muscle mass ratio increased from 0.58 +/- 0.13 to 0.69 +/- 0.12 ml/g (p less than 0.005). Ejection time increased from 276 +/- 17 to 296 +/- 17 ms (p less than 0.01), whereas no significant change was found for pre-ejection period, ejection fraction, cardiac index and LV dimensions. Doppler analysis revealed improved isovolumic relaxation time (116 +/- 17 vs. 84 +/- 28 ms; p less than 0.05), but no change in isovolumic contraction duration, maximal inflow velocities, time-velocity integrals and their duration, rate of acceleration and deceleration of early and atrial filling, and of their ratios. It is concluded that no reliable improvement in diastolic or systolic LV function is observed in chronic clonidine monotherapy of essential hypertension despite a normalization of blood pressure and a regression of LV hypertrophy.

Reduced atrial contribution to left ventricular filling in patients with severe tricuspid regurgitation after tricuspid valvulectomy: a Doppler echocardiographic study

Patients undergoing valvulectomy for isolated tricuspid valve endocarditis offer the unique opportunity to study the effects of acquired right ventricular volume overload on left ventricular filling in persons free of pulmonary hypertension and preexisting left heart disease. Eleven patients who had undergone total or partial removal of the tricuspid valve were compared with 11 age-matched control subjects; Doppler echocardiographic techniques were used to quantify changes in left ventricular filling and to relate them to changes in left ventricular and left atrial geometry caused by right ventricular and right atrial distension. The late diastolic fractional transmitral flow velocity integral, a measure of the left atrial contribution to left ventricular filling, was significantly decreased in patients undergoing tricuspid valvulectomy compared with control subjects (0.22 +/- 0.11 versus 0.32 +/- 0.09; p less than 0.04). Severe tricuspid regurgitation in these patients resulted in marked right atrial distension, reversal of the normal interatrial septal curvature and compression of the left atrium such that left atrial area was significantly smaller than in control subjects (5.9 +/- 2.2 versus 8.6 +/- 1.2 cm2/m2; p less than 0.005). Acting as a receiving chamber, the left ventricle was maximally compressed by the volume-overloaded right ventricle in late diastole, coincident with the timing of atrial systole, resulting in a significant increase in the left ventricular eccentricity index compared with that in control subjects (1.35 +/- 0.14 versus 1.03 +/- 0.1; p less than 0.001). Thus, right ventricular volume overload due to severe tricuspid regurgitation results in left heart geometric alterations that decrease left atrial preload, impair left ventricular receiving chamber characteristics and reduce the atrial contribution to total left ventricular filling.

Mitral regurgitation and diastolic flow profile in systemic sclerosis

To evaluate the left ventricular filling characteristics in systemic sclerosis, we examined 30 consecutive patients, 15 men and 15 women, and related the findings to those from 48 age- and sex-matched controls. All patients were investigated by pulsed and continuous wave mitral Doppler, and M mode echocardiography. We found the A wave of the mitral flow velocity as recorded by pulsed wave Doppler to be higher in patients (0.74 +/- 0.07 vs 0.54 +/- 0.02 m/sec, P less than 0.002), while the E wave did not differ. The high A/E ratio indicating reduced distensibility, correlated to interventricular septal thickness (r = 0.53, P less than 0.001), and atrial emptying index (r = -0.55, P less than 0.001). Early filling was impaired, with a prolonged pressure half time (99 +/- 6 vs 84 +/- 4 msec, P less than 0.05), and a reduced first third filling fraction (0.41 +/- 0.02 vs 0.48 +/- 0.01, P less than 0.001). Mitral regurgitation was found in 67% of systemic sclerosis patients and in 15% of controls (P less than 0.001). Doppler measures of left ventricular filling properties were not related to the presence of mitral regurgitation or systolic blood pressure. We conclude that left ventricular distensibility and early filling properties are impaired in systemic sclerosis and not related to blood pressure, but rather to left ventricular wall thickness and therefore probably secondary to myocardial fibrosis. Mitral regurgitation is a common finding in systemic sclerosis.

Doppler assessment of left ventricular filling pattern in silent ischemia in patients with Prinzmetal's angina

Spontaneous angina is an ideal condition in which to study left ventricular (LV) dysfunction induced by acute myocardial ischemia. In 6 patients with Prinzmetal's angina, LV diastolic function during 16 episodes of spontaneous angina was studied by simultaneous recordings of electrocardiographic (ECG), echocardiographic and hemodynamic parameters. In particular, pulsed Doppler echocardiography measured peak velocity of early (E) and late (A) transmitral flow and E/A ratio, as indexes of relative early versus late LV filling. During the ischemic attacks, the time sequence of pulsed Doppler echocardiographic and ECG changes showed 3 distinct phases: (1) "waxing phase: transmitral flow changes with minimal ECG modifications (E/A = 0.85 +/- 0.1); (2) "steady" phase: maximal ECG changes (E/A = 0.9 +/- 0.1); and (3) "waning" phase: regression of the ECG changes (E/A = 1.26 +/- 0.15). In each phase, E/A ratio showed a significant difference from the baseline value (E/A = 1.17 +/- 0.2) as a result of changes in E, suggesting that myocardial ischemia affects mainly the early phase of diastole. In the waxing phase, LV diastolic dysfunction preceded systolic abnormalities, as documented by a significant reduction of E/A ratio in the absence of alterations in LV ejection fraction, as well as in systemic arterial and pulmonary wedge pressures. Finally, all the recorded parameters were consistent with LV "contractile rebound" occurring in the waning phase and affecting both diastole and systole.

Determination of diastolic function by radionuclide ventriculography

Diastolic filling can be measured by radionuclide ventriculography with use of several techniques including those based on gated and list-mode acquisitions, the first-pass method, and the nuclear probe. Radionuclide ventriculography specifically assesses volumes, rates of volume change, and intervals during ventricular filling. Normal values for diastolic filling measurement vary depending on the individual radionuclide methods used and the age of the patient. Comparative studies of the radionuclide method with contrast angiographic and Doppler echocardiographic techniques for measuring diastole are discussed, and the advantages and disadvantages of the radionuclide techniques are explored. The role of radionuclide assessment of diastolic function in specific clinical examples of hypertrophic cardiomyopathy, hypertension, anthracycline-induced cardiomyopathy, and coronary artery disease is reviewed. Radionuclide ventriculography is an accurate and easily applicable procedure for studying left ventricular volume changes in diastole.

Improved diastolic LV filling after acute application of ajmaline in patients with coronary artery disease and normal systolic LV function

To determine whether ajmaline (A) can be safely applied in coronary artery disease (CAD), changes of left ventricular (LV) function after acute ajmaline application were analyzed by pulsed Doppler echocardiography in 10 CAD patients. LV pressures in systole and end-diastole and LVEF remained normal and comparable. Doppler normalized peak filling rate (p less than 0.02), peak early/atrial filling velocity (E/A) ratio (p less than 0.01) and E-deceleration (p less than 0.05) increased. The increase in E/A and in E-deceleration relative to base values was directly correlated (p less than 0.001). PEP increased, LVET remained unchanged. LV diastolic filling is improved after acute application of ajmaline in patients with CAD and normal systolic function; its application may be advised not only for therapy of arrhythmia but also to improve left ventricular diastolic mechanics in these patients.

Effect of age on diastolic left ventricular filling at rest and during inotropic stimulation and acute systemic hypertension: experimental studies in conscious beagles

"Pharmacologic" stress testing with inotropic stimulation is useful in the detection of coronary artery disease when ventricular dysfunction is provoked. However, abnormal diastolic filling may be masked or mimicked because of the influence of aging, heart rate, and loading conditions. We evaluated age effects on left ventricular filling at rest in young (n = 5) and old (n = 6) purebred beagles that were free of occlusive coronary disease and left ventricular hypertrophy, and we also evaluated age-related differences in left ventricular filling velocities in response to dobutamine and phenylephrine. Pulsed Doppler echocardiography of left ventricular filling velocities was performed at baseline and then after the administration of dobutamine (10 to 20 micrograms/kg/min) infusion. Repeat baseline recordings were obtained and then phenylephrine was administered intravenously in doses of 5 to 25 micrograms/kg/min until systolic arterial pressure increased by at least 30 mm Hg above baseline. At baseline, Doppler echocardiography revealed that there were no significant differences in the early (E) velocity or velocity time interval (VTI), and atrial (A) velocity or the A/E velocity ratio between the young and old groups. However, the A VTI and the A/(A + E) VTI ratio were significantly increased in the old group. With dobutamine administration, the E velocity did not significantly increase from baseline in either group. The E VTI, A velocity and A VTI increased significantly in both groups, but the increases were not different between groups. With phenylephrine infusion there was a significant decrease in the E VTI in the old group but neither the A/E velocity or the A/(A + E) VTI ratio significantly changed from baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsed Doppler evaluation of right ventricular diastolic filling in children with pulmonary valve stenosis before and after balloon valvuloplasty

To assess right ventricular (RV) diastolic filling in children with pulmonary stenosis (PS), 14 patients (mean age 5.1 years) were examined immediately before and after pulmonary balloon valvuloplasty. Fourteen normal children (mean age 4.8 years) were also studied. From the tricuspid valve inflow Doppler study, the following measurements were made at peak inspiration: peak velocities at rapid filling (peak E) and during atrial contraction (peak A), ratio of peak E to peak A velocities, RV peak filling rate normalized for stroke volume, total area under the Doppler curve, percent of the total Doppler area occurring in the first third of diastole (0.33 area fraction), percent of the total area occurring under the E wave (E area fraction), percent of the total area occurring under the A wave (A area fraction) and the ratio of E area to A area. Before balloon valvuloplasty, the patients with PS had higher peak A velocity (0.64 +/- 0.28 vs 0.39 +/- 0.08 m/s), lower E/A velocity ratio (1.11 +/- 0.52 vs 1.76 +/- 0.45), lower 0.33 area fraction (0.34 +/- 0.14 vs 0.49 +/- 0.08), higher A area fraction (0.45 +/- 0.21 vs 0.27 +/- 0.09) and lower E/A area ratio (1.73 +/- 1.05 vs 2.96 +/- 1.14) than the normal subjects (p less than 0.01). In patients before and after balloon valvuloplasty, there was a significant difference in RV outflow gradient (71 +/- 35 vs 28 +/- 15 mm Hg), but there was no change in any Doppler index. Thus, patients with PS have abnormal diastolic filling with decreased filling in early diastole and increased filling during atrial contraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Diastolic function in patients undergoing coronary angioplasty: influence of degree of revascularization

To assess the early effects of successful coronary angioplasty on Doppler-derived left ventricular filling patterns and the significance of the extent of revascularization on these variables, 31 patients undergoing coronary angioplasty were examined within 24 h before and after the revascularization procedure. After angioplasty, the peak early to late velocity ratio increased from 0.89 +/- 0.2 to 1.05 +/- 0.3 (p less than 0.0001) and the one-third filling fraction increased from 42 +/- 10% to 48 +/- 10% (p less than 0.0001). The percent atrial contribution to filling decreased from 45 +/- 7% to 41 +/- 8% (p less than 0.01), and the pressure half-time and the isovolumetric relaxation time shortened from 55 +/- 15 to 43 +/- 13 ms (p less than 0.001) and from 100 +/- 14 to 82 +/- 17 ms (p less than 0.0001), respectively. When comparing patients with complete (n = 23) and incomplete (n = 8) revascularization, the same changes in the Doppler variables were observed. However, the mean rate of acceleration of early filling increased significantly after angioplasty only in those patients with complete revascularization. These data indicate that the left ventricular diastolic filling pattern is modified significantly as early as 24 h after successful coronary angioplasty. Improvement in impaired relaxation appears to be the most likely explanation for these changes, although increased myocardial stiffness in patients with incomplete revascularization is an alternative hypothesis.

Influence of myocardial infarction size on radionuclide and Doppler echocardiographic measurements of diastolic function

To assess the relation between myocardial infarction size and diastolic function as measured by radionuclide ventriculography and Doppler echocardiography, 83 patients (aged 58 +/- 9 years) without significant valvular disease were studied 8 to 12 weeks after an acute myocardial infarction. Myocardial infarction size was measured by resting thallium-201 tomography. Peak early filling rate (in end-diastolic volumes/s) was measured by gated blood pool scintigraphy. Doppler measures of mitral inflow were peak early (E) and atrial (A) filling velocities, slopes of E and A, percent E and A filling, E/A ratio and diastolic filling period. In univariate analyses, there was a significant inverse correlation between infarction size and the peak early filling rate (r = -0.59, p less than 0.001), and this remained significant (r = -0.63, p less than 0.0001) in an analysis that included 2 other determinants of the filling rate, age and diastolic filling period. Infarction size was directly correlated to the peak E velocity (r = 0.37, p less than 0.01), deceleration of E (r = 0.41, p less than 0.01) and percent E filling (r = 0.31, p less than 0.01), and was inversely correlated to peak A (r = -0.27, p less than 0.05) and percent A filling (r = -0.26, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanical loads and the isovolumic and filling indices of left ventricular relaxation

In this report we have emphasized the significant influence of loading conditions on LV relaxation. Changes in inotropic state, ischemia, hypertrophy, and a host of other factors were not discussed herein. Ventricular asynchrony is likewise beyond the scope of this review, but it should be recognized that complex loading interactions among fibers within the LV wall influence relaxation and filling in ventricles that contract and relax nonsynchronously. Intact heart and isolated muscle experiments indicate that changes in preload do not influence relaxation rates when systolic pressure or total load remains constant. It appears, therefore, that the relaxation changes that occur with volume loading are primarily due to changes in systolic pressure or load. Indeed, an increase in systolic pressure may cause a substantial decrease in isovolumic relaxation rate, especially if there is a slow rise and a late peak in LV pressure. By contrast, an abrupt increase in late systolic load augments relaxation rate. Intact heart studies indicate that an abrupt load increment near the end of ejection results in premature and more rapid isovolumic relaxation, while an increase in left atrial pressure increases the filling rate; isolated muscle studies indicate that a load increment at the end of isometric relaxation causes an increase in isotonic relaxation rate. Thus, loading conditions during the periods of ejection, isovolumic relaxation, and filling can influence relaxation parameters and should be considered in clinical and experimental studies of LV relaxation.

Left ventricular filling at elevated diastolic pressures: relationship between transmitral Doppler flow velocities and atrial contribution

The relationship between transmitral Doppler blood flow velocities and atrial contribution to left ventricular (LV) filling was investigated in seven open-chest dogs. At LV filling pressures greater than 15 to 20 mm Hg, LV volume approaches a maximum. Thus we hypothesized that when LV pressure before the onset of atrial systole exceeds this level, the atrial contribution would decrease and the ratio between peak early (E) and atrial-induced (A) mitral velocities would increase. Atrial contribution was measured as LV diameter increase during atrial contraction expressed as a percentage of the total LV diameter change during diastole (sonomicrometry). When left ventricular end-diastolic pressure (LVEDP) was progressively increased from 10 +/- 1 (mean +/- standard deviation) to 28 +/- 3 mm Hg by intravenous saline solution, the atrial contribution decreased from 34 +/- 14% to 8 +/- 10% (p less than 0.001). Concomitantly the A velocity decreased from 39 +/- 7 to 24 +/- 8 cm.sec-1 (p less than 0.01), and the E/A ratio increased from 1.8 +/- 0.3 to 3.6 +/- 1.5 (p less than 0.001). The E/A ratio and the atrial contribution were constant until LVEDP exceeded 17 to 20 mm Hg, at which level marked changes in both parameters were noted. Thus when LV filling pressure was increased, the E/A ratio increased, indicating a filling shift towards early diastole. The reduced atrial contribution during increased preload was explained by the curvilinear shape of the LV pressure-volume curve. At markedly elevated filling pressures, near-maximum LV diameter was achieved before atrial contraction; hence the atrial contribution decreased and the E/A ratio increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of alteration in loading conditions on both normal and abnormal patterns of left ventricular filling in healthy individuals

Doppler analysis of mitral flow provides a means of analyzing left ventricular (LV) diastolic function. While experimental studies have suggested that changes in left atrial pressure may affect the normal pattern of early diastolic filling, the effect of such changes on abnormal patterns of filling is unknown. Accordingly, the Doppler pattern of LV filling was analyzed in 20 subjects with LV hypertrophy (mean age 59 +/- 13 years, +/- standard deviation), in 25 healthy normal subjects (29 +/- 6 years) and in 11 elderly subjects (68 +/- 5 years). All underwent Doppler examination of LV inflow at rest and immediately after postural changes. In all 3 groups, head-down positioning increased early diastolic flow velocity (E) (p less than 0.001), and raised the E to late diastolic flow velocity (A) ratio (p less than 0.01). However, an abnormal E/A ratio never approached a normal resting value. Likewise, although E and the E/A ratio decreased significantly in normal subjects with head-up positioning, it did not become abnormal. The magnitude of change in E, A and E/A ratio did not differ among the 3 groups in response to postural changes. Thus, alterations of LV loading conditions alter the pattern of LV filling, whether normal or abnormal at baseline. The magnitude of change appears to be independent of the resting flow pattern. Although loading conditions may affect the Doppler pattern of filling, simple changes in venous return do not "normalize" an abnormal pattern, nor do they "abnormalize" a normal pattern.

Assessment of diastolic filling indexes obtained by radionuclide ventriculography

This study assesses how differences in residual volume and heart rate influence the measurement and interpretation of commonly used indexes of left ventricular filling obtained by radionuclide ventriculography. Thirty patients with hypertrophic cardiomyopathy (HC) and 26 normal subjects were studied. The time to peak filling rate (168 +/- 42 vs 139 +/- 35 ms; p = 0.006) and time to 30% filling (154 +/- 32 vs 131 +/- 29 ms; p = 0.009 were prolonged in patients with HC compared to normal subjects, suggesting impaired early diastolic filling. However the peak filling rate, measured in end-diastolic counts/s, was greater in patients with HC (3.31 +/- 0.89 vs 3.06 +/- 0.51, p = 0.19). This measurement was influenced by the relative residual volume (HC r = 0.41, p less than 0.001; normal r = 0.29, difference not significant), which was smaller in patients with HC (22.4 +/- 8.0 vs 35.5 +/- 5.6%; p less than 0.0001). The peak filling rate measured in stroke volume counts did not vary with the relative residual volume (HC r = 0.10, difference not significant; normal r = 0.21, difference not significant) and was less than normal in patients with HC (4.27 +/- 0.69 vs 4.72 +/- 1.0; p = 0.58). There was a strong association between the first third filling fraction and the heart rate (HC r = 0.66, p less than 0.001; normal r = 0.71, p less than 0.001), reflecting its dependence on the duration of the first third of diastole.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of left ventricular diastolic performance

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

Effect of the second-generation calcium channel blocking drug nisoldipine on diastolic left ventricular dysfunction in heart failure

The effect of intravenous nisoldipine (0.12 microgram/kg/min) on diastolic left ventricular (LV) dysfunction was studied from simultaneous hemodynamic and radionuclide measurements in 12 patients with New York Heart Association class II to IV cardiac failure. The initial LV filling fraction was low, the peak LV filling rate normalized for end-diastolic volume was decreased, and the pulmonary capillary wedge pressure (PCWP) was high and associated with clinical shortness of breath. Nisoldipine produced an increase in LV filling fraction from 36 +/- 17% to 43 +/- 20% (p = 0.003). The increase in filling took place in both early and late diastole: peak early filling rate (PFR) increased in 11 of the 12 patients (p = 0.02) and late diastolic filling rate (atrial [A] wave in eight of them (NS). When the determinants of these changes, were examined further, it was found that in the control state PFR was inversely related to LV end-systolic volume (r = 0.77), whereas the A wave was related in exponential fashion to PCWP (preload) (r = 0.79). Nisoldipine did not change the slope of these relationships, and it did not alter the end-diastolic pressure-volume relationship, implying that inherent myocardial relaxation and distensibility were unaltered by the drug. In summary, nisoldipine improved measurements of diastolic LV dysfunction in patients with cardiac failure. This study illustrates the importance of considering ventricular loading conditions when analyzing and interpreting measurements of diastolic ventricular dysfunction. The measured changes in diastolic LV function during infusion of nisoldipine appear to be due to alterations in ventricular loading conditions rather than to a direct myocardial effect of the drug.

Hemodynamic benefit of atrioventricular synchrony: prediction from baseline Doppler-echocardiographic variables

The purpose of this study was to determine if baseline Doppler-echocardiographic variables of systolic or diastolic function could predict the hemodynamic benefit of atrioventricular (AV) synchronous pacing. Twenty-four patients with a dual chamber pacemaker were studied. Baseline M-mode and two-dimensional echocardiograms were obtained and Doppler-echocardiographic measurements of mitral inflow and left ventricular outflow were made in VVI mode (single rate demand) and in VDD (atrial synchronous, ventricular inhibited) and DVI (AV sequentially paced) modes at AV intervals ranging from 50 to 300 ms. Forward stroke volume and cardiac output were determined in each mode at each AV interval from the left ventricular outflow tract flow velocities, and the percent increase in cardiac output over VVI mode was determined. M-mode measurements, including left ventricular end-diastolic dimension, shortening fraction and left atrial size and Doppler measurement of diastolic filling, including peak early velocity and percent atrial contribution, did not correlate with the percent increase in cardiac output during physiologic pacing. The stroke volume in VVI mode correlated significantly with the percent increase in cardiac output during physiologic pacing (r = -0.61, p less than 0.005 for VDD mode and r = -0.55, p less than 0.05 for DVI mode). Five of the 15 patients with VVI stroke volume less than 50 ml but none of the 9 patients with stroke volume greater than 50 ml had ventriculoatrial (VA) conduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a single dose of isosorbide-5-mononitrate on the left ventricular diastolic function in systemic hypertension

The effect of a single dose of isosorbide-5-mononitrate on left ventricular (LV) diastolic function was assessed by radionuclide ventriculography in 18 hypertensive patients. The effect of the mononitrate on atrial filling also was assessed. As expected, there was a significant decrease in mean blood pressure (120 +/- 17 to 102 +/- 18 mm Hg, p less than 0.005). Global LV ejection fraction did not show a significant change, increasing slightly from 64 +/- 9 to 68 +/- 8% (difference not significant). The mononitrate prolonged the time to peak filling rate from 176 +/- 36 to 195 +/- 29 ms (p less than 0.0001). The percentage of time to peak filling rate from diastole also increased, from 46 to 53% (p less than 0.05), whereas the normalized peak filling rate did not change (2.36 +/- 0.6 to 2.31 +/- 0.6 end-diastolic volumes/s, difference not significant). This effect on LV diastolic function was closely related to a certain reduction in preload, as suggested by the reduction in mean left atrial filling (45 +/- 12 to 40 +/- 13 counts/s, p less than 0.005) and LV diastolic counts, suggesting that the "impairment" of diastolic function induced by nitrates is secondary to the reduction in venous return to the left atrium. The mononitrate did not affect the mean right atrial filling rate (50 +/- 12 to 52 +/- 13 counts/s) and the right ventricular end-diastolic counts, suggesting a primary vasodilatory effect of nitrates on the pulmonary vascular bed.

Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure

One hundred fifty-one consecutive patients with a diagnosis of congestive heart failure (CHF) referred for echocardiography were prospectively evaluated to (1) define the frequency of normal left ventricular systolic function in a referral-based population with CHF; (2) establish cardiac mechanisms responsible for symptomatology in these patients; and (3) assess the ability to clinically differentiate these subsets of patients based on routine history and physical examination. Of the 151 total patients, 51 (34%) had normal left ventricular systolic function (left ventricular ejection fraction greater than or equal to 55%). Primary valvular disease was present in 4 of these 51 patients (8%), and Doppler echocardiographic evidence of abnormal left ventricular filling (diastolic dysfunction) was evident in 10 (20%). In addition, no predefined resting abnormality was noted in 34 (66%) of them. Despite this finding, 51% of all patients with normal left ventricular systolic function were being treated with digoxin therapy in the absence of atrial arrhythmia. Clinical differentiation of this group of patients from those with abnormal left ventricular systolic function was difficult and may have accounted for this apparently inappropriate treatment. Thus, evaluation of left ventricular function and of causative mechanisms of CHF before initiation of long-term treatment is mandatory.

Age-dependency of left ventricular filling dynamics and relaxation as assessed by pulsed Doppler echocardiography

Left ventricular diastolic function was assessed from transmitral flow velocity curves as measured by Doppler echocardiography in healthy individuals aged 21-69 years, each decade comprising 12 subjects. By ageing, progressive changes in the various filling parameters were observed. When comparing the youngest and oldest age groups, the ratio between peak velocities in early and late diastole decreased from 2.0 +/- 0.3 to 1.2 +/- 0.3 (P less than 0.001). The filling fraction of first third of diastole decreased from 54 +/- 5% to 45 +/- 4% (P less than 0.001). Isovolumic relaxation time increased from 61 +/- 11 ms to 77 +/- 12 ms (P less than 0.01). Correlation coefficients of velocity ratio, filling fraction and isovolumic relaxation time vs. age were r = -0.71 (P less than 0.001), r = -0.56 (P less than 0.001) and r = 0.44 (P less than 0.001), respectively. When isovolumic relaxation time and age were used together in multivariate regression analysis, only age was an independent predictor of velocity ratio and filling fraction. Stroke volume, peak velocity in left ventricular outflow tract, heart rate and systolic blood pressure were similar in all age groups. Thus, velocity ratio and filling fraction indicated a relative filling shift towards late diastole by ageing and were more sensitive than systolic parameters in reflecting age-related changes in cardiac function. The changes could be explained neither by delayed relaxation nor by change in systolic parameters. When using Doppler echocardiography for evaluation of left ventricular filling, age-matching of reference groups is necessary.

Effects of verapamil on left ventricular relaxation and filling dynamics in coronary artery disease: a study by pulsed Doppler echocardiography

The effect of verapamil on left ventricular diastolic function in coronary artery disease was assessed by Doppler echocardiography of transmitral flow velocities in 20 patients. At baseline, isovolumic relaxation time was prolonged compared with that in 18 age-matched normal subjects (95 +/- 13 msec versus 74 +/- 12 msec, p less than 0.001), but decreased to 80 +/- 14 msec (p less than 0.001) after treatment. The ratio between early and atrial-induced transmitral velocities (E/A-ratio) at baseline was lower in patients than in normal subjects (1.1 +/- 0.2 versus 1.4 +/- 0.3, p = 0.01), as was the filling fraction of the first third of diastole (43% +/- 5% versus 50% +/- 4%, p less than 0.001). Verapamil treatment increased the E/A-ratio to 1.3 +/- 0.4 (p less than 0.001) and filling fraction to 45% +/- 4% (p = 0.055) because of increased early filling. No change in systolic performance or heart rate was observed. Thus, coronary artery disease was associated with retarded relaxation and impairment of early filling. However, verapamil treatment enhanced relaxation and induced a filling shift toward early diastole, which indicated improved diastolic performance. The changes probably reflected reduced myocardial ischemia.

Pulsed Doppler assessment of left ventricular diastolic filling in children with left ventricular outflow obstruction before and after balloon angioplasty

To assess left ventricular (LV) diastolic filling in children with pressure overload hypertrophy, 12 patients with LV outflow obstruction (7 with aortic valve stenosis and 5 with aortic coarctation) and 12 healthy, age-matched control subjects were examined. Each child underwent M-mode echocardiography and pulsed Doppler examination of the LV inflow. The patients with LV outflow obstruction had cardiac catheterization and balloon angioplasty. Their echo/Doppler examinations were performed in the catheterization laboratory before and immediately after balloon angioplasty. From the M-mode echocardiogram, the LV cavity dimensions and wall thicknesses, LV mass and shortening fraction were measured. The following measurements were made from the Doppler recording: peak velocities at rapid ventricular filling (peak E) and during atrial contraction (peak A), ratio of peak E to peak A velocities, total area under the Doppler curve, percent of the total Doppler area occurring in the first one-third of diastole (0.33 area fraction), percent of the total area occurring under the E wave (E area fraction), percent of the total area occurring under the A wave (A area fraction) and the ratio of E area to A area.(ABSTRACT TRUNCATED AT 250 WORDS)