Effect of volume reduction on mitral annular diastolic velocities in hemodialysis patients

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/'preserved' left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258-271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient's bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59-G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

Echocardiographic assessment of pulmonary capillary wedge pressure by E/e' ratio: A systematic review and meta-analysis

BACKGROUND

The reliability of echocardiographic methods for the assessment of pulmonary capillary wedge pressure (PCWP) is still a matter of debate. Since its first description, the E/e' ratio has been regarded as a suitable method. The aim of this study is to evaluate the evidence of how E/e' effectively estimates PCWP and its diagnostic accuracy for elevated PCWP.

METHODS

We systematically searched MEDLINE and Embase databases for studies investigating the agreement between E/e' and PCWP, from inception to July 2022. We limited our research to studies published from 2010 to date. Retrospective studies and studies on non-adult population were excluded.

RESULTS

Twenty-eight studies, involving a total of 1964 subjects, were included. The pooled analysis of the studies showed a modest correlation between E/e' and PCWP. The weighted average correlation (r) is 0.43 (95% CI 0.37-0.48). We found no significant differences between reduced and preserved ejection fraction groups. Thirteen studies analysed the diagnostic accuracy of E/e' for elevated PCWP. The AUC of receiver operating characteristic curves for PCWP >15 mmHg was estimated in the interval 0.6-0.91.

DISCUSSION

E/e' appears to have a modest correlation with PCWP and an acceptable accuracy for elevated PCWP. (PROSPERO number, CRD42022333462).

Cardiac Doppler Parameters and Progress in Clinical Manifestation of Primary Lower Extremity Varicose Veins: A Prospective Study in China

Objective

To investigate the features of cardiac Doppler parameters in patients with primary lower extremity varicose veins in China.

Materials and Methods

We performed a prospective statistical analysis of cardiac Doppler parameters between 129 Chinese patients with varicose veins and normal controls. Furthermore, we evaluated the relationship between cardiac Doppler and the progress or severity of lower extremity varicose veins.

Results

Compared with normal controls, patients with primary varicose veins had significantly lower early mitral and tricuspid diastolic inflow and annular velocities (E- and e′-waves), significantly higher late mitral and tricuspid diastolic inflow and annular velocities (A- and a′-waves), significantly higher mitral systolic annular velocities (s′-wave), and significantly lower mitral and tricuspid E/A ratio. There was no significant association between deep venous reflux (DVR) of the lower extremities and cardiac Doppler parameters. The relationship between Clinical Etiological Anatomical Pathophysiological (CEAP) clinical class and cardiac Doppler parameters showed on that: In comparison with normal control, all cardiac Doppler parameters of C2 clinical class patients were basically unchanged, but the cardiac Doppler parameters of the C3 or higher CEAP class patients changed. Hence, we found a potential CEAP grade cut-off value (C3) linked to statistical changes in cardiac Doppler parameters.

Conclusion

Cardiac Doppler parameters in patients with primary varicose veins could indeed be different from those of normal people, especially for C3 class or higher CEAP clinical class patients. Therefore, for those patients, pre-operative echocardiography can be used to evaluate cardiac hemodynamic changes, but large-scale clinical promotion requires further large sample studies.

The effect of overweight/obesity on diastolic function in children and adolescents: A meta-analysis

Left ventricular diastolic function (LVDF) is an important marker of early cardiovascular remodelling, which has not been well summarized in young people with overweight/obesity. Weighted, random-effects regression was used to determine the strength of associations of both body mass index (BMI) and homeostatic model assessment of insulin resistance (HOMA-IR) with LVDF measures, adjusting for age and sex. Six databases were searched after PROSPERO registration (CRD42020177470) from inception to July 2020 for studies that compared LVDF between overweight/obesity and control groups aged ≤24 years, yielding 70 studies (9983 individuals). Quality and risk of bias were assessed using NHLBI tools, with scores of good, fair, and poor for 6, 48, and 16 studies, respectively. Increased BMI was associated with worse LVDF in all measures except early mitral inflow deceleration time, with septal early diastolic tissue peak velocity to late diastolic tissue peak velocity ratio having the strongest association (n = 13 studies, 1824 individuals; r = -0.69; P < 0.001). Elevated HOMA-IR was also associated with worse LVDF. Although we could not determine the causality of reduced LVDF in young people, our findings should aid the development of paediatric guidelines for the assessment of LVDF and support further work to address the longitudinal consequences of childhood obesity and IR on LVDF.

Changes in left ventricular and atrial mechanics and function after dialysis in patients with end-stage renal disease

Background

Hemodialysis (HD) can influence end-stage renal disease (ESRD) patients' circulatory system. The present study aimed to evaluate the effect of volume depletion on left ventricular (LV) and left atrial (LA) function and determine the volume-independent parameters before and after HD in patients with ESRD.

Methods

Between January 2018 and January 2019, we recruited long-term HD patients (n=40, 51.0±16.4 years), excluding those with structural cardiac disease. Echocardiographic parameters, including LV and LA volumes, flow Doppler, pulsed tissue Doppler, and speckle tracking echocardiography (STE) before and after HD (within 24 h), were examined, and the values were compared.

Results

Following HD, alteration in LV end-systolic volume was not detected, whereas LV end-diastolic volume (90.18±23.91 vs. 84.21±23.54 mL, P=0.036) and LV ejection fraction (LVEF; 64.63%±6.56% vs. 62.84%±6.56%, P=0.049) decreased. Peak early diastolic trans-mitral flow velocity (E-wave; 82.22±20.13 vs. 72.43±18.32 cm/s, P<0.001), peak early diastolic tissue Doppler velocity (e'; 6.45±1.88 vs. 5.77±1.63 cm/s, P<0.001) at the septal side of the mitral annulus, the ratio of early to late Doppler velocities of diastolic mitral inflow (0.90±0.27 vs. 0.79±0.23, P<0.001), and the average E/e' ratio (12.54±4.08 vs. 11.28±4.52, P=0.049) decreased significantly. No significant difference was found in peak blood flow velocity at the mitral valve during late diastole and e' at the lateral side of the mitral annulus after HD. LA volume index (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), tricuspid regurgitation velocity (260.11±36.54 vs. 242.37±32.22 cm/s, P=0.002), and pulmonary artery systolic pressure (33.63±11.29 vs. 29.94±7.80 mmHg, P=0.006) significantly decreased. LV global longitudinal systolic strain (GLS) of 4-chamber view (-24.37%±3.02% vs. -23.38%±3.33%, P=0.019), rather than global circumferential systolic strain, exhibited significant change after HD. Significant changes were also found in LV longitudinal early diastolic strain rate (LSRe; 1.17±0.25 vs. 1.05±0.24 s^-1, P<0.001) and early diastolic global radial velocity (Ve; 2.62±0.59 vs. 2.25±0.67 cm/s, P=0.011) after HD, but not in other strain rates and global radial velocity measurements. LA maximal volume (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), LA total emptying fraction (54.19%±10.39% vs. 49.63%±11.05%, P=0.009), and LA passive emptying fraction (32.23%±12.86% vs. 26.81%±9.28%, P=0.004) decreased significantly after HD, while LA minimal volume, the volume at the onset of atrial systole, and LA active emptying fraction after HD were not significantly different.

Conclusions

Most indices of systolic (LVEF and GLS of 4-chamber view) and early diastolic function (E-wave, e', LSRe, global radial Ve, and LA passive emptying fraction) were preload dependent. Late diastolic indices, including LV late diastolic global longitudinal strain rate, late diastolic global radial velocity, and LA active emptying fraction, did not change with volume depletion.

Left ventricular myocardial function in hemodialysis patients: the effects of preload decrease in conventional, Doppler and speckle tracking echocardiography parameters

Introduction

our aim was to investigate the value of conventional echocardiography, pulsed Doppler and speckle tracking imaging (STI) analysis in the assessment of the left ventricular (LV) myocardial function in hemodialysis (HD) patients with preserved LV ejection fraction and to evaluate the effect of a single HD session on the LV systolic and diastolic functions.

Methods

the study population consisted of 30 chronic HD patients. Echocardiography and Doppler studies were performed before and after HD. The LV global longitudinal, circumferential and radial strains were measured with two and three-dimensional STI.

Results

after HD, LV dimensions, left atrium (LA) area, systolic pulmonary arterial pressure and inferior vena cava diameter decreased significantly. The peak mitral E velocity, the E/A ratio of the mitral inflow and the lateral E/E´ ratio decreased also significantly. The LV and LA volumes index and LV mass index (LVMi) decreased remarkably after HD. The 3D- LV and LA ejection fractions were unchanged after HD. Although, 3D-estimated LVEF seemed to be preserved in the HD patients, the 2D and 3D- strain rates were decreased in all directions. The global strain values improved in all directions after a single HD session. Inverse correlations were found between the LVMi, serum BNP and LV global longitudinal strain.

Conclusion

in HD patients with preserved LV ejection fraction, the STI analysis may add important information concerning the subclinical LV dysfunction.

Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction

Background

The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP).

Aim

This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients.

Methods and Results

This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e′ (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e′ (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e′ (r = 0.62, p < 0.001 for E/e′_mean).

Conclusion

Only stress echocardiography derived tissue Doppler E/e′ ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea.

Clinical Trial Registration

https://www.clinicaltrials.gov, identifier NCT03620526.

Role of Lung Ultrasound in Adjusting Ultrafiltration Volume in Hemodialysis Patients

Chronic fluid over-hydration is common in dialysis patients. It is associated with mortality and cardiovascular events. Optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. The purpose of this study was to evaluate the usefulness of ultrasound in quantifying body water. In 35 hemodialysis patients, we performed ultrasound of the chest, pre-tibial skin tissue thickness (TT), heart and inferior vena cava (IVC) before and after dialysis. We compared B-line scores of lungs, IVC diameters and cardiac functions in pre-dialysis and post-dialysis groups. We then estimated the correlations between ultrasound parameters and ultrafiltration volumes. Ultrafiltration parameters were adjusted prospectively for subsequent dialysis. As a result, both extravascular and intravascular water decreased during ultrafiltration. The median numbers of B-line scores (10 [0-42] vs. 4 [0-30]; p < 0.001); mitral valve blood flow velocities E (0.83 ± 0.23 m/s vs. 0.70 ± 0.20 m/s; p < 0.001), A (0.93 ± 0.28 vs. 0.89 ± 0.23 m/s; p < 0.001) and E/e' (12.47 ± 4.92 vs. 10.37 ± 4.0; p < 0.001); IVC diameters at end-expiration (17.51 ± 3.33 mm vs. 14.26 ± 3.45 mm; p < 0.001); and right pre-tibial TT (2.86 ± 1.36 mm vs. 2.43 ± 1.24 mm; p < 0.001) decreased during dialysis. Ultrafiltration volume was most associated with B-line score (adjusting for age and sex) (β = -3.340; p = 0.003). In addition, the B-line score after dialysis was significantly associated with left ventricular ejection fraction (r = -0.393; p = 0.019) and TT (r = -0.447; p = 0.007). Ultrafiltration volume was prospectively increased then if the B-line score was >6 in the previous dialysis. All patients tolerated the protocol well without any symptoms. Ultrafiltration volume was most associated with lung water, reflected by variation in B-line score. It was not associated with cardiac function, IVC diameter, IVC collapse rate or TT. Lung ultrasound is a useful imaging tool for dialysis patients.

Left ventricular dysfunction by conventional and tissue Doppler echocardiography in pediatric hemodialysis patients: relation with plasma brain natriuretic peptide levels

INTRODUCTION

Tissue Doppler imaging (TDI) is a relatively new echocardiography method in children with chronic kidney disease (CKD). The aims of this study were to evaluate left ventricular (LV) diastolic function in pediatric CKD patients using conventional pulsed-wave Doppler echocardiography (cPWD) and TDI methods and correlate them with BNP levels.

MATERIAL AND METHODS

Thirty children on regular hemodialysis (HD) were included. Left ventricular systolic and diastolic indices and BNP levels were measured immediately before and after HD.

RESULTS

After HD, LV and left atrium diameters were significantly decreased (p < 0.001 and p < 0.001, respectively). Transmitral E velocity and E/A ratio decreased (p < 0.001 and p < 0.001, respectively). Also, there were significant decreases in the early diastolic velocity E' of LV wall, septal wall, and anterior wall (p = 0.001, p = 0.004 and p < 0.001, respectively). Mean E/E' ratio and ratios of septal and lateral walls were decreased significantly (p = 0.004, p = 0.002 and p = 0.017, respectively). BNP levels decreased significantly during HD when comparing concentrations before and after HD (p < 0.001). BNP strongly correlated with LV diastolic function indices (before HD: mean E/E' (r = 0.401, p = 0.028), lateral E/E" (r = 0.291, p = 0.025), septal E'(r = -0.398, p = 0.029), lateral wall E' (r = -0.452, p = 0.012) and mean E' (r = -0.469, p = 0.009), after HD: mean E/E' (r = 0.38, p = 0.038) and lateral E/E" (r = 0.474, p = 0.008) and lateral wall E' (r = -0.270, p = 0.037)).

CONCLUSIONS

The cPWD and TDI-derived LV indices are influenced by HD. The diagnostic utility of BNP in the presence of deteriorating renal function may be compromised to some extent.

Assessment of the left ventricular function in normotensive prediabetics: a tissue Doppler echocardiography study

OBJECTIVE

Several studies have shown that left ventricular (LV) dysfunction is increased in individuals with diabetes. However, there are scarce data about LV function in prediabetics. This study assessed the early changes in LV diastolic and systolic myocardial function in normotensive prediabetics using tissue Doppler echocardiography (TDE).

SUBJECTS AND METHODS

We evaluated 94 patients with prediabetes (mean age of 50.8 ± 6.9 years, 78 female) without known cardiovascular diseases and 70 healthy volunteers with similar demographic characteristics. Systolic and diastolic function of the left ventricle was evaluated with transthoracic echocardiography according to the latest consensus recommendations including TDE.

RESULTS

The mean results of septal and lateral parts of the mitral annulus Pulsed wave TDE showed that myocardial systolic wave (Sm), myocardial early diastolic wave (Em) and Em to atrial peak velocity (Am) ratio were significantly lower whereas early diastolic peak flow velocity (E) to Em ratio, myocardial isovolumetric relaxation time (IVRTm), myocardial isovolumetric contraction time (IVCTm) and myocardial performance index (MPI) values were significantly higher in patients with prediabetes (preDM). In addition, mean left atrium (LA) diameter measured with M-mode echocardiography was significantly higher in prediabetics than controls.

CONCLUSION

PreDM is associated with subclinical LV systolic and diastolic dysfunction as evaluated by TDE.

Noninvasive assessment of exercise tolerance using mitral annular velocities

PURPOSE

To investigate the feasibility of evaluating exercise tolerance using lateral and septal mitral annular velocities in patients with preserved left ventricular ejection fraction (LVEF) and those with reduced LVEF.

METHOD

We studied 36 patients with LVEF ≥50% and 36 with LVEF <50%. We measured peak early diastolic velocity of transmitral flow (E) and peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus. The ratios of E to LEa (E/LEa) and E to SEa (E/SEa) were calculated. We measured peak oxygen consumption [Formula: see text] and anaerobic threshold (AT) by cardiopulmonary exercise testing.

RESULTS

In patients with LVEF ≥50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.69 and r = -0.74, respectively; p < 0.001); E/SEa correlated modestly (r = -0.59 and r = -0.60, respectively; p < 0.001). In patients with LVEF <50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.72 and r = -0.76; respectively, p < 0.001); E/SEa correlated modestly (r = -0.63 and r = -0.63, respectively; p < 0.001).

CONCLUSION

E/LEa may be more useful than E/SEa for the noninvasive estimation of exercise tolerance, throughout a wide range of LVEF.

Can we diagnose isolated, exercise-induced heart failure with normal ejection fraction?

BACKGROUND

A significant proportion of patients with exertional dyspnea require exercise to diagnose heart failure with normal ejection fraction (HFNEF).

METHODS AND RESULTS

In this review article, we evaluate current data on the prevalence, clinical significance and specifically the establishment of a diagnosis of isolated, exercise-induced HFNEF. Despite the unquestioned clinical importance and high prevalence of exercise-induced HFNEF, there are limited and conflicting data on making a diagnosis of exercise-induced HFNEF. This mostly relies on the evidence of exercise-induced elevation in left ventricular filling pressure (LVFP). At present, there is no agreement on the ability of exercise echocardiographic parameteres to predict exercise-induced LVFP elevation. In addition, even invasively measured exercise LVFP faces the problem of defining normal exercise LVFP values. More data and probably new diagnostic approaches are necessary to reliably diagnose exercise HFNEF.

CONCLUSIONS

There are conflicting results and significant problems associated with the diagnosis of exercise HFNEF. This review hopefully will encourage further research in this difficult but clinically important area of heart failure.

Impaired left ventricular filling in COPD and emphysema: is it the heart or the lungs? The Multi-Ethnic Study of Atherosclerosis COPD Study

BACKGROUND

COPD and heart failure with preserved ejection fraction overlap clinically, and impaired left ventricular (LV) filling is commonly reported in COPD. The mechanism underlying these observations is uncertain, but may include upstream pulmonary dysfunction causing low LV preload or intrinsic LV dysfunction causing high LV preload. The objective of this study is to determine if COPD and emphysema are associated with reduced pulmonary vein dimensions suggestive of low LV preload.

METHODS

The population-based Multi-Ethnic Study of Atherosclerosis (MESA) COPD Study recruited smokers aged 50 to 79 years who were free of clinical cardiovascular disease. COPD was defined by spirometry. Percent emphysema was defined as regions &lt; -910 Hounsfield units on full-lung CT scan. Ostial pulmonary vein cross-sectional area was measured by contrast-enhanced cardiac magnetic resonance and expressed as the sum of all pulmonary vein areas. Linear regression was used to adjust for age, sex, race/ethnicity, body size, and smoking.

RESULTS

Among 165 participants, the mean (± SD) total pulmonary vein area was 558 ± 159 mm2 in patients with COPD and 623 ± 145 mm2 in control subjects. Total pulmonary vein area was smaller in patients with COPD (-57 mm2; 95% CI, -106 to -7 mm2; P = .03) and inversely associated with percent emphysema (P &lt; .001) in fully adjusted models. Significant decrements in total pulmonary vein area were observed among participants with COPD alone, COPD with emphysema on CT scan, and emphysema without spirometrically defined COPD.

CONCLUSIONS

Pulmonary vein dimensions were reduced in COPD and emphysema. These findings support a mechanism of upstream pulmonary causes of underfilling of the LV in COPD and in patients with emphysema on CT scan.

Positive End-expiratory Pressure Influences Echocardiographic Measures of Diastolic Function

Background:

Ultrasonography of the cardiovascular system is pivotal for hemodynamic assessment. Diastolic function is evaluated with a combination of tissue Doppler (e’ and a’) and pulsed Doppler (E and A) measures of transmitral- and mitral valve annuli velocities. However, accurate echocardiographic evaluation in the intensive care unit or perioperative setting is contingent on relative resistance to positive pressure ventilation and changes in preload. This study aimed to evaluate the effects of positive end-expiratory pressure (PEEP) and positioning on echocardiographic measures of diastolic function.

Methods:

The study was a prospective, randomized, crossover study. Cardiac surgery patients with ejection fraction greater than 45% and averaged e’ of 9 or more were included. Postoperatively, anesthetized patients were randomized into six combinations of PEEP (0, 6, 12 cm H2O) and positions (horizontal, Trendelenburg). At each combination, e’ (primary endpoint), a’, E, and A were obtained with transesophageal echocardiography along with left ventricular area. Image analysis was performed blinded to the protocol.

Results:

Thirty patients completed the study. PEEP decreased lateral e’ from 6.6 ± 3.6 to 5.3 ± 3.0 cm/s (P &lt; 0.001) in the horizontal position and from 7.4 ± 4.2 to 6.5 ± 3.3 cm/s (P &lt; 0.001) in Trendelenburg. Similar results were found for septal e’, a’ bilaterally and transmitral pulsed Doppler measures, and PEEP decreased left ventricular area. E/A, E/e’, and e’/a’ remained unaffected by PEEP and positioning.

Conclusions:

When evaluating diastolic function by echocardiography, the levels of PEEP and its effect on ventricular area have to be taken into account. In addition, this study dissuades the use of E/e’ for tracking changes in left ventricular filling pressures in cardiac surgery patients.

Echocardiographic Measures of Diastolic Function Are Preload Dependent during Triggered Positive Pressure Ventilation: A Controlled Crossover Study in Healthy Subjects

Background. The use of echocardiography in intensive care settings impacts decision making. A prerequisite for the use of echocardiography is relative resistance to changes in volume status and levels of positive pressure ventilation (PPV). Studies on indices of diastolic function report conflicting results with regard to dependence on volume status. Evidence is scarce on PPV. Methods. Ten healthy subjects were exposed to 6 levels of positive end-expiratory pressure (PEEP) and pressure support (PS) following a baseline reading. All ventilator settings were performed at three positions: horizontal, reverse-Trendelenburg, and Trendelenburg. Echocardiography was performed throughout. Results. During spontaneous breathing, early diastolic transmitral velocity (E) changed with positioning (P < 0.001), whereas early diastolic velocity of the mitral annulus (e') was independent (P = 0.263). With PPV, E and e' proved preload dependent (P   values < 0.001). Increases in PEEP, PS, or a combination influenced E and e' in reverse-Trendelenburg- and horizontal positions, but not in the Trendelenburg position. Discussion. The change towards preload dependency of e' with PPV suggests that PPV increases myocardial preload sensitivity. The susceptibility of E and e' to preload changes during PPV discourages their use in settings of volume shifts or during changes in ventilator settings. Conclusion. Positioning and PPV affect E and e'.

The value of E/Em ratio in the estimation of left ventricular filling pressures: impact of acute load reduction: a comparative simultaneous echocardiographic and catheterization study

BACKGROUND

The ratio of the early transmitral flow velocity to the early diastolic tissue velocity (E/Em) has been suggested as a reliable estimate of left ventricular diastolic pressures (LVDP). However, the evidence regarding the ability of E/Em to detect LVDP changes is relatively equivocal. Our aim was to evaluate the validity of the ratio following acute load reduction.

METHODS AND RESULTS

68 consecutive patients referred for coronary angiography underwent LV catheterization and echocardiography simultaneously. Doppler signals of transmitral flow and spectral TD signals at the level of the mitral annulus were obtained before and directly after intravenous administration of nitroglycerin (NTG). The predictive ability of E/Em to identify elevated LVDP was modest (area under curve=0.71 ± 0.08, p<0.01). The index was more strongly associated with LVDP in patients with reduced ejection fraction (EF)<55% (r=0.68; p<0.01) than in patients with normal EF. Following NTG, E/Em lacked any predictive potential for elevated LVDP whereas changes LVDP could not be reliably tracked using E/Em.

CONCLUSION

The predictive capacity of E/Em for elevated LVDP was weak and declined significantly following acute reduction in LV load. Changes in LVDP were not reliably predicted by E/Em. The current findings derived from a real-world patient population with relatively high filling pressures indicate that E/Em may not be sufficiently robust to be employed as a single non-invasive estimate of LVDP nor for monitoring load reducing medical therapy.

Pharmacotherapy of heart failure with normal ejection fraction (HFNEF)--a systematic review

AIM

The pharmacotherapy for heart failure with normal ejection fraction (HFNEF) is not as well defined as that for the treatment for heart failure with reduced ejection fraction (HFREF). Studies of the various drugs given for HFNEF have revealed conflicting results. The aim of this systematic review was to determine whether there is any benefit with pharmacotherapy in HFNEF in terms of cardiac outcomes.

METHODS

Electronic and printed sources were searched until August 2010 for randomized controlled clinical trials (RCTs) comparing drug therapy with placebo in HFNEF. Weighted mean difference and pooled odds ratio (OR) with 95% confidence intervals were calculated.

RESULTS

A total of six RCTs including 8410 patients with a mean follow-up period of 21 months were included in the analysis. Although there were no significant differences in all cause mortality between the two groups (pooled OR 0.95, 95% CI 0.79, 1.13, P= 0.55), the subgroup analysis revealed a slight but non significant advantage with the β-adrenoceptor blocker group. There was no significant difference between the two groups in terms of cardiovascular mortality, hospitalization, worsening heart failure, ejection fraction, E : A ratio, deceleration time and E : E' ratio.

CONCLUSION

There was no significant benefit of pharmacotherapy in HFNEF. This might have been because of a lack of stringent inclusion criteria for patients in the trials and lower power of the studies. Hence trials with well defined inclusion criteria, better power, longer follow-up periods and with echocardiographic parameters as endpoints are required to shed further light on this topic.

Perioperative assessment of diastolic dysfunction

Assessment of diastolic function should be a component of a comprehensive perioperative transesophageal echocardiographic examination. Abnormal diastolic function exists in >50% of patients presenting for cardiac and high-risk noncardiac surgery, and has been shown to be an independent predictor of adverse postoperative outcome. Normalcy of systolic function in 50% of patients with congestive heart failure implicates diastolic dysfunction as the probable etiology. Comprehensive evaluation of diastolic function requires the use of various, load-dependent Doppler techniques This is further complicated by the additional effects of dehydration and anesthetic drugs on myocardial relaxation and compliance as assessed by these Doppler measures. The availability of more sophisticated Doppler techniques, e.g., Doppler tissue imaging and flow propagation velocity, makes it possible to interrogate left ventricular diastolic function with greater precision, analyze specific stages of diastole, and to differentiate abnormalities of relaxation from compliance. Additionally, various Doppler-derived ratios can be used to estimate left ventricular filling pressures. The varying hemodynamic environment of the operating room mandates modification of the diagnostic algorithms used for ambulatory cardiac patients when left ventricular diastolic function is evaluated with transesophageal echocardiography in anesthetized surgical patients.

Noninvasive Estimation of the Rate of Relaxation by the Analysis of Intraventricular Pressure Gradients

Background—

During late ejection, myocardial relaxation causes systolic flow to decelerate and stop, and this phenomenon is coupled with the generation of a pressure gradient inside the left ventricle (LV). We hypothesized that the peak reverse ejection intraventricular pressure difference (REIVPD) between the LV apex and the outflow tract could be a useful method to improve the assessment of LV relaxation using Doppler echocardiography.

Methods and Results—

Three sets of animal experiments and 1 clinical study were designed. In 6 pigs, a close relationship between REIVPD and the intensity of the relaxation wave ( R rm =0.89) was demonstrated using wave intensity analysis of high-fidelity pressure-volume-velocity data. In 19 animals, REIVPD sensitively detected modifications of the lusotropic state and closely correlated with the time constant of LV relaxation (τ) within animals ( R rm =−0.93). Load-dependence analysis in 5 pigs showed that REIVPD remained stable up to values of 35% to 40% acute preload reduction. Clinical validation was tested in 50 patients (23 with normal systolic function) undergoing simultaneous Doppler echocardiography and high-fidelity LV pressure measurements on the same beat. REIVPD and tissue Doppler mitral annulus velocity (e′) were independently related to τ, but the REIVPD · e′ product correlated better with τ than either variable separately (bootstrap-corrected correlation coefficients: R =−0.84 versus −0.71, and −0.70, respectively, P <0.05). Area under the receiver operating characteristic curve to predict impaired relaxation (τ>50 ms) for e′ · REIVPD was 0.96 (95% confidence interval, 0.85 to 0.99).

Conclusions—

The Doppler-derived REIVPD provides a sensitive, reliable, reproducible, and relatively load-independent index of the rate of LV relaxation. Combined with tissue Doppler measurements of longitudinal function, this method improves noninvasive assessment of LV relaxation in the clinical setting.

[Effects of acute decrease in preload on echocardiographic indices of systolic and diastolic function of the left ventricle in children with end-stage renal disease (ESRD). Comparative study before and after hemodialysis]

PURPOSE

Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children.

METHODS

Thirty-five children with chronic renal failure (15 males, aged 12.8+/-3.8 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared.

RESULTS

Hemodialysis led to reduction in LV end-diastolic volume (p=0.001), end-systolic volume (p=0.05), left atrium area (p<0.0001), peak early (E wave) transmitral flow velocity (p=0.005), peak S velocity of pulmonary vein flow (p=0.002), aortic time velocity integral (p<0.0001) and aortic ejection time (p<0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly (p=0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly (p=0.042) after hemodialysis.

CONCLUSIONS

Most of Doppler-derived indices of diastolic function are preload-dependent. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.

Effects of Altered Volume Loading on Left Ventricular Hemodynamics and Diastolic Filling During Hemodialysis

BACKGROUND

Changes in the circulating volume associated with hemodialysis (HD) resulted in alternations of left ventricular (LV) filling. However, previous studies offered conflicting findings. This study thus evaluated the impact of HD on LV diastolic filling indices and hemodynamics.

MATERIALS AND METHODS

Forty patients with end-stage renal disease were studied by Doppler echocardiography immediately before and after HD. The cardiac size, volume and mass were determined by M-mode and two-dimensional echocardiography. LV diastolic filling parameters and hemodynamics were assessed from mitral inflow using Doppler echocardiography.

RESULTS

Left atrial and LV dimension, LV volume, and LV mass decreased significantly after HD (p<0.001). Cardiac output declined from 5.74+/-1.37 to 4.98+/-1.27 L/min (p<0.001), whereas, the ejection fraction remained unchanged. HD elicited marked changes in the early diastolic E (95.1+/-20.5 to 70.3+/-18.2 cm/s, p<0.001) and late atrial filling A velocities (104.3+/-20.9 to 88.9+/-16.9 cm/s, p<0.001). In addition, correction of the deceleration time of E and isovolumic relaxation time prolonged significantly (p=0.011 and p<0.001, respectively).

CONCLUSIONS

Findings in this study indicate that HD altering the loading condition significantly influenced the LV diastolic function and hemodynamics. Moreover, Doppler echocardiography provides an effective means of assessing the effects on LV diastolic filling and hemodynamics during HD.

Usefulness of the ratio of transmitral E wave velocity to isovolumic relaxation flow propagation velocity for predicting left ventricular end-diastolic pressure

Transmitral E wave velocity was reported to be positively related to left ventricular (LV) filling pressure and negatively related to LV relaxation constant, and isovolumic relaxation flow propagation velocity (IRFPV) was proven recently to be negatively related to LV relaxation constant and independent of preload alterations. Therefore, the combination index, E/IRFPV, may eliminate the influence of LV relaxation and bring the LV filling pressure into focus. However, it is unknown whether E/IRFPV is a useful index in prediction of LV filling pressure. The aim of this study is to evaluate the correlation between E/IRFPV and LV end-diastolic pressure (LVEDP). Forty-three patients with suspected coronary artery disease who underwent a Doppler echocardiographic study and cardiac catheterization were included. LVEDP was determined by a micromanometer-tipped catheter. In a univariate analysis, LVEDP had a positive correlation with left atrial dimension, LV end-diastolic dimension, LV end-systolic dimension, the ratio of E to E wave propagation velocity (EPV) (r = 0.408, p = 0.007), the ratio of E to early diastolic mitral annular velocity (Ea) (r = 0.439, p = 0.003) and E/IRFPV (r = 0.686, p < 0.001). It had a negative correlation with diastolic blood pressure, E wave deceleration time, LV ejection fraction, EPV, Ea and IRFPV. After stepwise multiple linear regression analysis, only the E/IRFPV was the independent predictor of LVEDP (beta = 0.667, p < 0.001). In conclusion, E/IRFPV is a useful parameter in prediction of LVEDP.

Preload dependence of the time interval between onsets of mitral inflow and early diastolic mitral annular velocity: a study in healthy subjects

The time interval (TEa-E) between onsets of early diastolic mitral annular velocity (Ea) and early mitral inflow velocity (E) has been proposed as a new index of left ventricular (LV) relaxation. We aimed to assess the influence of preload changes on this parameter by examining 25 healthy volunteers at rest, after passive leg lifting, and after administration of nitroglycerin combined with Valsalva maneuver. To obtain septal and lateral TEa-E, the time intervals between peak R-wave on electrocardiogram and the onsets of Ea and E were measured in different cardiac cycles. E and Ea were significantly changed by preload manipulations. We did not observe significant changes of TEa-E intervals after leg lifting or after nitroglycerin administration combined with Valsalva maneuver (P = NS). TEa-E was < 0 ms in several subjects using either septal or lateral Ea recordings. We conclude that TEa-E may be load independent in subjects with normal LV systolic and diastolic function as compared to other Doppler parameters. Therefore, this index could be potentially used as a reliable noninvasive parameter of LV relaxation. Nevertheless, even slight differences in cardiac cycle lengths might influence the measurements of TEa-E interval. For that reason, the clinical use of TEa-E seems to be significantly limited because of a wide margin of error in its measurement due to the inability to obtain Doppler recordings during the same cardiac cycle.

Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease

Left ventricular hypertrophy and systolic dysfunction predict mortality in patients with end-stage renal disease. However, the prognostic value of left ventricular filling pressure has remained uncertain in this population. We evaluated whether the early mitral inflow velocity to peak mitral annulus velocity (E/Em) ratio, an estimate of left ventricular filling pressure by tissue Doppler imaging, has significant additional prognostic value to conventional echocardiographic parameters and other clinical and biochemical parameters in 220 patients with end-stage renal disease. The E/Em ratio was elevated (>15) in 62% of the patients. Multivariate analysis showed that an elevated E/Em ratio had the highest correlation with left ventricular volume index, followed by loss of residual glomerular filtration rate, increasing age, worsening ejection fraction, and diabetes. During the median follow-up of 48 months, the E/Em ratio emerged as an independent predictor of all-cause mortality (adjusted hazard ratio: 1.027; 95% CI: 1.003 to 1.051; P=0.026) and cardiovascular death (adjusted hazard ratio: 1.033; 95% CI: 1.002 to 1.065; P=0.035) in the multivariable Cox regression analysis. In addition, the E/Em ratio added significant incremental prognostic value for all-cause mortality (P=0.035) and cardiovascular death (P=0.035) beyond the standard clinical, biochemical, and dialysis parameters and echocardiographic measurements. In conclusion, the E/Em ratio displayed important additional long-term prognostic information above and beyond that of left ventricular mass and systolic function. Our data suggest that left ventricular filling pressure should be estimated during echocardiographic examination for additional prognostication in patients with end-stage renal disease.

Diagnosis of left ventricular diastolic dysfunction in the setting of acute changes in loading conditions

Introduction

Conventional pulsed wave Doppler parameters are known to be preload dependent, whereas newly proposed Doppler indices may be less influenced by variations in loading conditions. The aim of the present study was to evaluate the effects of haemodialysis-induced preload reduction on both conventional and new Doppler parameters for the assessment of left ventricular (LV) diastolic function.

Methods

This prospective observational study was conducted in a medical-surgical intensive care unit (ICU) and nephrology department of a teaching hospital. In total, 37 haemodialysis patients with end-stage renal disease (age [mean ± standard deviation]: 52 ± 13 years) and eight ventilated ICU patients with acute renal failure receiving vasopressor therapy (age 57 ± 16 years; Simplified Acute Physiology Score II 51 ± 17) were studied. Echocardiography was performed before and after haemodialysis. Conventional pulsed wave Doppler indices of LV diastolic function as well as new Doppler indices, including Doppler tissue imaging early diastolic velocities (E' wave) of the septal and lateral portions of the mitral annulus, and propagation velocity of LV inflow at early diastole (Vp) were measured and compared before and after ultrafiltration.

Results

The volume of ultrafiltration was greater in haemodialysis patients than in ICU patients (3.0 ± 1.1 l versus 1.9 ± 0.9 l; P = 0.005). All conventional pulsed wave Doppler parameters were altered by haemodialysis. In haemodialysis patients, E' velocity decreased after ultrafiltration when measured at the septal mitral annulus (7.1 ± 2.5 cm/s versus 5.9 ± 1.7 cm/s; P = 0.0003), but not at its lateral portion (8.9 ± 3.1 cm/s versus 8.3 ± 2.6 cm/s; P = 0.37), whereas no significant variation was observed in ICU patients. Vp decreased uniformly after ultrafiltration, the difference being significant only in haemodialysis patients (45 ± 11 cm/s versus 41 ± 13 cm/s; P = 0.04). Although of less magnitude, ultrafiltration-induced variations in Doppler parameters were also observed in haemodialysis patients with altered LV systolic function.

Conclusion

In contrast to other Doppler parameters, Doppler tissue imaging E' maximal velocity measured at the lateral mitral annulus represents an index of LV diastolic function that is relatively insensitive to abrupt and marked preload reduction.

Isovolumic relaxation flow propagation velocity: a promising load-independent relaxation parameter in hemodialysis patients

The aim of this study is to evaluate whether isovolumic relaxation flow propagation velocity (IRFPV), a newly proposed relaxation parameter, is independent of load alterations. Thirty-nine uremic patients (21 men; age 62 +/- 10 y) who underwent echocardiography 1 h before and 1 h after hemodialysis (HD) were included. After HD, body weight, systolic blood pressure, early transmitral filling wave velocity (E), early diastolic mitral annular velocity (Ea) and early diastolic inflow propagation velocity (EPV) decreased significantly (p <or= 0.007), while IRFPV kept constant (p = 0.550). A subgroup analysis showed that in patients with body weight reduction <2.5 kg, E (p = 0.005) decreased significantly, but Ea (p = 0.078), EPV (p = 0.155) and IRFPV (p = 0.324) did not change after HD. In patients with body weight reduction >or=2.5 kg, E (p < 0.001), Ea (p = 0.001) and EPV (p = 0.001) decreased significantly but IRFPV (p = 0.715) was still constant after HD. In conclusion, IRFPV may be a load-independent parameter in assessing left ventricular diastolic function. However, Ea and EPV are load-independent only at minor load alterations. In evaluating left ventricular diastolic function in HD patients whose loading conditions frequently vary with time, IRFPV seems to be more adequate than Ea and EPV.

Evaluation of alterations on mitral annulus velocities, strain, and strain rates due to abrupt changes in preload elicited by parabolic flight

We tested the hypothesis that in normal subjects, cardiac tissue velocities, strain, and strain rates (SR), measured by Doppler tissue echocardiography (DTE), are preload dependent. To accomplish it, immediately preceding image acquisition, reversible, repeatable, acute nonpharmacological changes in preload were induced by parabolic flight. DTE has been proposed as a new approach to assess left ventricular regional myocardial function by computing tissue velocities, strain, and SR. However, preload dependence of these parameters in normal subjects still remains controversial. DTE images (Philips) were obtained in 10 normal subjects in standing upright position at normogravity (1 G z), hypergravity (1.8 G z), and microgravity (0 G z) with and without −50 mmHg lower body negative pressure (LBNP). Myocardial velocity curves in the basal interventricular septum were reconstituted offline from DTE images, from which peak systolic (S′), early (E′) and late (A′) diastolic velocities, SR, and peak systolic strain (PSε) were measured and averaged over four beats. At 1.8 G z (reduced venous return), S′, E′, and A′ decreased by 21%, 21%, and 26%, respectively, compared with 1-G z values, while at 0 G z (augmented venous return), E′, A′, and PSε increased by 57%, 53%, and 49%, respectively. LBNP reduced E′ and PSε. In conclusion, our results were in agreement with those obtained in animal models, in which preload was changed in a controlled, acute, and reversible manner, and image acquisition was performed immediately following preload modifications. The hypothesis of preload dependence was confirmed for S′, E′, A′, and PSε, while SR appeared to be preload independent, probably reflecting intrinsic myocardial properties.

Tissue Doppler velocity is not totally preload-independent: a study in a uremic population after hemodialysis

OBJECTIVES

The aim of this study was to investigate the changes of regional tissue Doppler velocity after volume removal following regular hemodialysis (HD) in uremic patients. Is tissue Doppler velocity really preload-independent?

BACKGROUND

Diastolic dysfunction was divided into four stages: normal pattern, abnormal relaxation pattern, pseudonormalization pattern, and restrictive pattern. Pulse wave Doppler and color Doppler echocardiography were important diagnostic tools for these forms of diastolic dysfunction. However, they were preload-dependent and sometimes there was confusion between the normal pattern and the pseudonormalization pattern. Tissue Doppler echocardiography was promising for problems in diastolic dysfunction and appeared to be preload-independent. However, there are still some disputes over this point.

METHODS

Ninety-three uremic patients receiving regular HD were included in the study. There were 45 males and 48 females aged 59 +/- 14 years. The mean volume removed after HD was 2.3 +/- 0.9 kg. The mean heart rates before and after HD were 77 +/- 11 and 76 +/- 12 beats per minute, respectively (p = 0.73). All patients received complete transthoracic echocardiography examinations before and after HD. The studies included cardiac chamber size, left ventricular systolic performance, pulse wave Doppler echocardiographic data of mitral inflow and the right upper pulmonary vein including peak velocity of early diastolic E wave, E wave time velocity integral (TVI-E), peak velocity of late diastolic A wave, A wave TVI, systolic phase of pulmonary vein (S wave TVI), early diastolic phase of pulmonary vein (D wave TVI) and atrial contraction phase of pulmonary vein (Ar wave TVI). Pulsed tissue Doppler echocardiography (TDE) was performed and a 4-mm sample volume was placed at the 6 corners of the mitral annulus including septal, lateral, anterior, inferior, anteroseptal and posterior corners. Five to ten cardiac cycles were recorded and the data were averaged. Measurements performed included peak velocity of systolic phase (Sa), early diastolic phase (Ea), late diastolic phase (Aa), Ea/Aa ratio and time from the beginning of electrocardiogram Q wave to the beginning of Sa (Q-Sa time). The same measurements were repeated after HD.

RESULTS

After HD, left atrium diameter and left ventricular internal dimensions at end diastole became smaller. There were significant reductions for mitral peak E wave velocity, TVI-E, peak A wave velocity and E/A ratio. As for the pulmonary vein, systolic phase of pulmonary vein and early diastolic phase of pulmonary vein decreased significantly. Peak Ar wave did not change significantly. For TDE, Sa and Aa did not change but Ea did decrease.

CONCLUSION

After HD, there is a significant reduction of intravascular effective volume. No significant change is found for myocardial peak systolic velocity and peak late diastolic velocity. However, there is a significant reduction of myocardial early diastolic phase peak velocity. This suggests that TDE is not completely preload-independent; at least, it is phase-dependent within each cardiac cycle.

Ratio of Early Transmitral Velocity to Lateral Mitral Annular Early Diastolic Velocity Has the Best Correlation With Wedge Pressure Following Cardiac Surgery

BACKGROUND

Although previous investigators reported that mitral annular velocity predicts mean pulmonary capillary wedge pressure (PCWP), it is unknown whether the lateral or septal mitral annular velocity more faithfully predicts PCWP after cardiac surgery.

METHODS AND RESULTS

To assess the effect of cardiac surgery on the predictive values for PCWP by measuring mitral annular velocity, 52 consecutive patients undergoing cardiac surgery were studied. All patients underwent transthoracic echocardiography and right-sided cardiac catheterization both before and after surgery. The peak early diastolic velocity of transmitral flow (E) was measured by pulsed-wave Doppler and the peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus by pulsed-wave tissue Doppler imaging. The ratios of E to LEa (E/LEa) and SEa (E/SEa) were calculated. Immediately after echocardiography, PCWP was measured using a balloon-tipped pulmonary artery catheter. After surgery, LEa was significantly increased (6.4+/-2.7 vs 8.6+/-3.3 cm/s, p<0.001), but SEa was unchanged (6.0+/-2.5 vs 5.5+/-2.3 cm/s, p=0.09). E/LEa correlated well with PCWP both before and after surgery (r=0.79 and r=0.69, respectively, p<0.001). Although E/SEa correlated well before surgery (r=0.67, p<0.001), it correlated only weakly after surgery (r=0.44, p<0.01).

CONCLUSIONS

E/LEa has the best correlation with PCWP both before and after cardiac surgery and may be more useful than E/SEa in the noninvasive estimation of PCWP.

Left ventricular diastolic function in hemodialysis patients: role of preload increase maneuver on tissue Doppler imaging evaluation

OBJECTIVE

Tissue Doppler imaging (TDI) has recently been proposed as a relatively preload-independent method to evaluate left ventricular diastolic function. We sought to investigate the higher-accuracy of TDI to assess diastolic function in end-stage renal disease (ESRD) patients on hemodialysis (HD) associated with a preload increase maneuver.

METHODS

Thirty-two consecutiveESRD patients (16 female, ages 48.8 +/- 17.5 years, 14 <or=45 and 18 >45 years old) were evaluated. Measurements of E, A velocities and the E/A ratio from transmitral inflow pulsed wave Doppler, and E', A' velocities and the E'/A' ratio from TDI were obtained 1 h before and 1 h after HD at baseline and with a preload increase maneuver.

RESULTS

The E/A ratio changed significantly in all patients aged >45 before and after HD with the preload increase maneuver. The E'/A' ratio increased in all subjects with the preload increase maneuver before HD but did not change with the maneuver after HD in the euvolemic state in all patients.

CONCLUSION

In ESRD patients on routine HD, TDI evaluation associated with a preload increase maneuver proved to be a more accurate method to identify diastolic dysfunction when the evaluation is performed in euvolemic patients after HD.

Left Ventricular Filling Hemodynamics in Patients with Pulmonary Edema and Preserved Versus Reduced Left Ventricular Ejection Fraction: A Prospective Doppler Echocardiographic Study

BACKGROUND

Objective evidence of elevated left ventricular (LV) filling pressures is infrequently demonstrated in clinical practice in patients with heart failure (HF) and preserved LV ejection fraction (LVEF) and the clinical diagnosis of HF is commonly questionable in these patients. The objective of this study was to examine whether elevated LV filling pressures can be demonstrated noninvasively in consecutive patients with HF and preserved (vs reduced) LVEF.

METHODS

Echocardiography was performed in 141 patients hospitalized with acute pulmonary edema (within 3 days of admission in 83.6%). LV filling was assessed in 116 patients without significant valve disease (median age 76 years; 51.7% men) and LV filling pressures were estimated based on mitral and pulmonary venous flow patterns and mitral annular diastolic velocities.

RESULTS

LVEF was preserved (> or =45%) in 49 patients (42.2%) and reduced (<45%) in 67 patients (57.8%). In patients with in sinus rhythm, normal LV filling pattern and abnormal relaxation, pseudonormal, and restrictive LV filling patterns (the latter two patterns associated with elevated LV filling pressures) were evident in 8, 1, 11, and 9 patients with preserved LVEF, versus 5, 11, 15, and 23 patients with reduced LVEF, respectively (P = .01) (LV filling pattern was nonconclusive in 12 patients). In patients with atrial arrhythmias, elevated LV filling pressures were evident in 4 of 14 patients with preserved LVEF and 3 of 4 patients with reduced LVEF. Overall, elevated LV filling pressures were demonstrable in 24 patients with preserved LVEF (49.0%) and in 41 patients with reduced LVEF (68.3%) (P = .26).

CONCLUSIONS

Elevated LV filling pressures are frequently evident by Doppler echocardiography in patients with HF and preserved or reduced LVEF. Thus, Doppler echocardiography can provide objective noninvasive evidence of abnormal LV filling in a large proportion of patients with HF and preserved LVEF.

Stroke Volume and Mitral Annular Velocities: Insights from Uremic Patients with Significant Valvular Regurgitation

OBJECTIVE

This study investigates the change in new diastolic indices in uremic patients who undergo regular hemodialysis (H/D).

MATERIALS AND METHODS

We studied uremic patients receiving regular H/D. All patients were sinus rhythm before H/D. They had normal left ventricular systolic performance without regional wall motion abnormality. Patients were separated into two groups according to whether they had significant aortic or mitral regurgitation (AR or MR) or not. They received complete transthoracic echocardiographic examinations. Stroke volume (SV) was calculated as the product of the time-velocity integral (TVI) and cross-sectional area of aortic annulus. Flow propagation velocity (FPV) was measured by color M-mode echocardiography in apical four-chamber view. Mitral annulus tissue Doppler velocities--peak systolic (Sa), early diastolic, and late diastolic--were measured from septal and lateral wall. All these parameters were obtained immediately before and after H/D. Paired data were compared.

RESULT

H/D amount was strongly correlated with the change of SV. After H/D, the reduction of SV in patients without AR or MR (control group) was obvious but it was not significant in patients with significant AR or MR (study group). There were significant differences in mitral inflow velocities, FPV, and mitral annular velocities (except septal Sa) in the control group. In the study group, predialytic and postdialytic parameters of new diastolic indexes had no statistical difference.

CONCLUSION

New echocardiographic indexes of uremic patients with significant AR or MR were relatively preload-independent. The phenomenon was possibly related to insignificant change of SV after H/D.

Acute effects of hemodialysis on left ventricular function evaluated by tissue Doppler imaging

Evidence exists that left ventricular function is impaired in chronic uremic patients. During hemodialysis (HD) treatment, myocardium undergoes electrolyte, hemodynamic and neuro-humoral stress; however, data about the acute changes on ventricular function are controversial. Aim of the present study was to evaluate the effect of a single hemodialysis session on left ventricular (LV) systolic and diastolic function using pulsed tissue Doppler imaging (TDI) sampled by echocardiography. The study group included 20 uremic patients (17 males, aged 51+/-13 yrs) on maintenance HD, free from clinically overt cardiac dysfunction who underwent echocardiography with pulsed TDI 30 min prior and 30 min after a HD session. TDI was performed by placing the sample volume in the center of the basal lateral segment and the basal interventricular septum in the apical four-chamber view. Myocardial systolic wave (S(m)) and early (E(m)) and atrial (A(m)) diastolic waves were measured. On standard sonography examination, no significant changes in LV systolic function parameters were observed after HD, but the indices for LV diastolic function deteriorated significantly (peak E, 75.4+/-11.2 vs. 58.8+/-12.5 cm/s, P<0.01; E/A ratio, 1.0+/-0.3 vs. 0.8+/-0.2, P<0.01). However, regarding TDI measures following HD, the patients exhibited a lower S(m) peak (septum: 7.6+/-1.1 vs. 5.9+/-0.8 cm/s; lateral wall: 7.7+/-1.7 vs. 6.8+/-1.2 cm/s, P<0.001), a lower E(m) peak (septum: 8.3+/-1.6 vs. 6.3+/-1.7 cm/s; lateral wall: 10.2+/-2.4 vs. 7.1+/-1.9 cm/s, P<0.001), and a reduced E(m)/A(m) ratio (septum: 1.0+/-0.4 vs. 0.7+/-0.2; lateral wall: 1.2+/-0.5 vs. 0.7+/-0.2, P<0.001, respectively), as compared to pre-HD parameters. Of interest, peak E(m), and E(m)/A(m) ratio of the lateral wall were negatively related to ultrafiltration rate (r = -0.60, P<0.05 and -0.69, P<0.01, respectively). Our data indicate that a single hemodialysis session is associated with acute deterioration of diastolic and systolic parameters of myocardial function, as assessed by TDI. These reversible changes could be considered as a cardiac stunning that seems to be related to the ultrafiltration rate and then to the interdialysis weight gain. These findings suggest that low ultrafiltration volume and/or limited interdialytic weight gain are cardioprotective measures in hemodialysis patients.

Doppler Tissue Imaging and Color M-Mode Flow Propagation Velocity: Are They Really Preload Independent?

OBJECTIVE

This study investigated the change in new diastolic indexes in patients with uremia who undergo regular hemodialysis (H/D).

METHODS

We studied 81 patients with uremia (41 men and 40 women) receiving regular H/D. All patients were in sinus rhythm before H/D. They had normal left ventricular systolic performance without regional wall-motion abnormality. Three patients were excluded because of atrial fibrillation after H/D. Patients were separated by the amount of body fluid removed during H/D procedure: 30 patients with H/D amount less than 2 kg (group 1), 33 patients with H/D amount between 2 and 3 kg (group 2), and 18 patients with H/D amount larger than 3 kg (group 3). They received complete transthoracic echocardiographic examinations. Flow propagation velocity (FPV) was measured by color M-mode echocardiography in apical 4-chamber view. Mitral annulus Doppler tissue velocities (peak systolic [Sa], early diastolic [Ea], and late diastolic [Aa]) were measured from septal, lateral, inferior, and posterior walls. All these parameters were obtained immediately before and after H/D. Paired data were compared.

RESULTS

In patients with removed fluid amount less than 2 kg (group 1), the change of all diastolic parameters showed insignificant change except FPV (peak mitral E, P = .14; peak mitral A, P = .916; FPV, P = .009; septal Sa, P = .173; septal Ea, P = .295; septal Aa, P = .649). In patients with H/D amount between 2 and 3 kg, the change of all diastolic parameters showed statistically significant difference except Sa (peak mitral E, P = .001; peak mitral A, P = .001; FPV, P = .001; Sa, P = .589; Ea, P = .001; Aa, P = .015). In patients with H/D amount larger than 3 kg, Sa still showed insignificant change. Ea, Aa, and FPV showed significant difference after H/D (peak mitral E, P = .001; peak mitral A, P = .035; FPV, P = .008; septal Sa, P = .777; septal Ea, P = .014; septal Aa, P = .048).

CONCLUSION

In patients with normal left ventricular systolic function, FPV was preload dependent. Diastolic phase mitral annulus Doppler tissue velocities (Ea and Aa) behaved differently according to the amount removed during H/D. They were preload independent when the amount removed during H/D was less than 2 kg. When the amount removed during H/D was larger than 2 kg, diastolic phase mitral annulus Doppler tissue velocities changed significantly. That is to say, diastolic phase mitral annulus Doppler tissue velocities were not totally preload independent. For systolic phase mitral annulus Doppler tissue velocity index (Sa), it was preload independent.

Preload Dependence of Doppler Tissue Imaging Derived Indexes of Left Ventricular Diastolic Function

Doppler tissue imaging (DTI) has been proposed as a tool for the evaluation of diastolic function. Controversy exists regarding whether DTI measurements are influenced by preload. Changes in the circulating volume associated with hemodialysis result in preload reduction. To determine the influence of preload reduction on DTI and standard pulsed-Doppler transmitral diastolic velocities, 30 patients (mean age 41 +/- 14) with chronic renal insufficiency without overt heart disease were studied by DTI and standard pulsed Doppler before and after hemodialysis. From the apical window, DTI sample volume was placed at the lateral and septal mitral annulus and at the midsegment of lateral and septal myocardial wall of the left ventricle. Peak early diastolic annular and myocardial, and peak late diastolic annular and myocardial velocities were measured. Transmitral peak early and late diastolic velocities were also recorded by standard pulsed Doppler. The peak velocity of early diastolic mitral flow decreased from 100 +/- 30 to 85 +/- 34 cm/s (P < 0.001) after hemodialysis. Hemodialysis elicited marked reduction in early diastolic lateral mitral annular and midlateral myocardial velocities (6.9 +/- 3.2 to 6.3 +/- 2.9 cm/s, P < 0.04 and 6.7 +/- 0.3 to 5.5 +/- 2 cm/s, P < 0.001, respectively). Early diastolic, septal mitral annular, and midseptal myocardial velocities were also significantly decreased (5.8 +/- 2.8 to 4.6 +/- 2 cm/s, P < 0.006 and 6.2 +/- 2 to 5.1 +/- 1 cm/s, P < 0.008, respectively). Late diastolic mitral annular and myocardial velocities did not change. It is concluded that early diastolic mitral annular and myocardial velocities are affected by acute preload reduction. It is necessary to consider preload when diastolic function is assessed by DTI.

Evaluating preload dependence of a novel Doppler application in assessment of left ventricular diastolic function during hemodialysis

BACKGROUND

Left ventricular (LV) diastolic dysfunction, commonly found in hemodialysis (HD) patients, is a major cause of intradialytic hypotension. Conventional Doppler interrogation of mitral flow velocities typically is load dependent. Tissue Doppler imaging (TDI) recently was proposed as a new and relatively load-independent approach to assess diastolic function. The aim of this study is to determine whether HD-related volume reduction affects mitral annular velocities in a large number of patients.

METHODS

One hundred twenty-eight uremic patients underwent Doppler echocardiography 1 hour before and after HD. Two-dimensional and M-mode echocardiography were used to analyze LV size, volume, mass, systolic function, and the inferior vena cava. Doppler signals were obtained from the mitral inflow and TDI of the mitral annulus to measure variations in hemodynamics and LV diastolic filling parameters.

RESULTS

After HD, LV size, volume, mass, stroke volume, and cardiac output were significantly decreased (all P < 0.001). Peak early (E) and late diastolic velocities (A) and E/A ratio decreased significantly after HD (all P < 0.001). Mitral annulus E' velocity and E'/A' ratio also changed significantly (both P < 0.001), whereas A' did not. Consequently, changes in E and A significantly differed with respect to the varying amount of ultrafiltration (both P < 0.05).

CONCLUSION

Our larger cohort study shows that the proposed technique of TDI is still volume dependent. Therefore, LV diastolic function in HD patients must be assessed carefully in a timely manner, even when the new Doppler application is used.

The effect of isolated ultrafiltration on Doppler-derived indices of left ventricular diastolic function

BACKGROUND

Haemodialysis (HD) is associated with acute changes simultaneously in fluid status (ultrafiltration) and in many biochemical parameters (dialysis). Reports on the effects of these changes on left ventricular (LV) diastolic function are scant. This study evaluated the effect of isolated ultrafiltration (UF) and subsequent HD with minimal fluid removal on Doppler-derived indices of LV diastolic function in patients who were asymptomatic and stable on HD.

METHODS

In 11 HD cases, the 5 h treatment session was divided into a 2.5 h period of fluid removal without dialysis (UF phase) and 2.5 h of dialysis with minimal fluid removal (HD phase). We examined the following parameters of LV diastolic function echocardiographically: early rapid filling (Emax), atrial peak filling (Amax), Emax/Amax ratio, isovolumic relaxation time (IVRT) and deceleration time of the E-wave (DT).

RESULTS

During the UF phase, Emax decreased from 0.82 +/- 0.2 to 0.62 +/- 0.2 m/s (P = 0.003), Amax decreased from 0.72 +/- 0.2 to 0.63 +/- 0.2 m/s (P = 0.042) and the ratio Emax/Amax did not change (P = NS). During the HD phase, Emax increased from 0.62 +/- 0.2 to 0.72 +/- 0.2 m/s (P = 0.018), Amax increased from 0.63 +/- 0.2 to 0.70 +/- 0.3 m/s (P = NS) and the Emax/Amax ratio remained unchanged (P = NS). IVRT was prolonged in 10 out of 11 patients at the start of the UF phase and it was further prolonged from 142 +/- 40 to 171 +/- 55 ms (P = 0.03) during the UF phase. IVRT did not alter during the HD phase (P = NS). During the UF phase, DT increased from 175 +/- 83 to 244 +/- 119 and it decreased from 244+/-119 to 209 +/- 98 in the HD phase, but both changes were statistically insignificant. No statistically significant correlations were observed between the changes in the Doppler indices of diastolic function and changes in biochemical parameters during the HD phase.

CONCLUSIONS

UF affects the parameters Emax, Amax and IVRT used to evaluate LV diastolic function. The changes in Emax and Amax during the HD phase are due to fluid refilling from tissues into the blood space, HD as such having no effect on Doppler indices. However, isolated UF or HD does not affect the Emax/Amax ratio. Emax and IVRT seem to be the most volume-sensitive parameters.

Effect of preload reduction by hemodialysis on left atrial volume and echocardiographic Doppler parameters in patients with end-stage renal disease

Left atrial (LA) volume has been proposed as a less preload-dependent parameter of diastolic function than Doppler mitral inflow. We hypothesize that in the absence of mitral regurgitation and atrial fibrilation, LA enlargement could be a more practical (and relatively preload-independent) method for the evaluation of left ventricular diastolic function. The aim of the present study was to determine the effects of preload reduction by hemodialysis on LA volume.