Left ventricular filling in hypertrophic cardiomyopathy: a pulsed Doppler echocardiographic study

Linear periodization of strength training in blocks attenuates hypertension and diastolic dysfunction with normalization of myocardial collagen content in spontaneously hypertensive rats

BACKGROUND AND METHOD

This study evaluated the effects of a linear block strength training programme on the parameters of cardiac remodelling in spontaneously hypertensive rats. Thirty-nine rats were equally distributed in four groups: normotensive sedentary, normotensive trained, hypertensive sedentary and hypertensive trained. The strength training protocol was organized in three mesocycles of 4 weeks, with an increase in the training load organized in a linear fashion for each block, considering the weight established in the maximum loaded load test. The following parameters were evaluated: ventricular function assessed by echocardiogram, caudal blood pressure, ventricular haemodynamics and cardiac masses. Two-way analysis of variance was used to determine the differences between the group and time.

RESULTS

After 12 weeks of training, the hypertensive trained group presented the following results: increased muscle strength, reduced blood pressure, reduced heart rate, isovolumetric relaxation time and total collagen content, with increased cardiac function, without promoting changes in the mass and nuclear volume of cardiomyocytes. Also, blood pressure reduction seems to be associated with both muscle strength adjustments and total load progress.

CONCLUSION

The findings of this study showed that the training programme carried out attenuated systemic arterial pressure and preserved the ventricular function of spontaneously hypertensive rats without cardiac mass change.

Reduced cardiac output and its correlation with coronary blood flow and troponin in asphyxiated infants treated with therapeutic hypothermia

Perinatal asphyxia can lead to multi-organ insult which includes cardiovascular dysfunction. The objective was to study the relationship between cardiac function, perfusion and troponin. Unit database was accessed to identify infants with perinatal asphyxia over the last 2 years. Information from medical records and archived echocardiographic images was retrieved. Comparisons for echocardiographic information were made with healthy term infants. Seventeen infants with perinatal asphyxia were identified, of which three were excluded (one-33 weeks gestation, two-coagulopathy and pulmonary hypertension); 14 infants received therapeutic hypothermia. Median (range) gestation and birthweight were 39 (37-42) weeks and 3,550 (2,380-3,992) g respectively. Mean (S.D.) rectal temperature and time of echocardiogram were 33.5 ± 0.5 °C and median (range) 7.7 h [3-10] respectively. Majority of infants had low biventricular outputs. Median (range) SVC flow was 29.8 ml/kg/min (13-96.2). Median (range) troponin was 0.77 μg/L (0.17-2.6); normal ≤ 0.08 μg/L. Markedly low coronary flows (diastolic VTI median (range) 2.1 (1.3-2.9) cm were noted compared to controls. Coronary flow had a significantly positive correlation with left ventricular output. Higher troponin levels were associated with lower aortic stroke velocity. A close association between cardiac output, perfusion and troponin was noted. A dichotomy between blood pressure and flow parameters was noted, indicating the wide variation in vascular resistance in these infants. Biventricular output, coronary and SVC flows were significantly higher in the control population. In conclusion, inter-variable relationship between cardiac output, coronary flow and troponin is an important addition to the understanding of cardiovascular impact of perinatal asphyxia.

The progression of left ventricular systolic and diastolic dysfunctions in hypertrophic cardiomyopathy: clinical and prognostic significance

OBJECTIVES

The significance of the progression of systolic and diastolic dysfunctions in hypertrophic cardiomyopathy (HCM) is still an open issue. We sought to evaluate the clinical and prognostic implications of the progression of left ventricular systolic and diastolic dysfunction in HCM.

METHODS

One hundred one HCM patients were studied by echo-Doppler at baseline and during follow-up.

RESULTS

During a follow-up of 109 + or - 67 months, 28% of patients showed a progression to left ventricular diastolic dysfunction, defined as restrictive filling pattern (RFP), and 16% to left ventricular systolic dysfunction (left ventricular ejection fraction <50%). The 10-year heart transplant-free survival rate was 45% in patients with RFP at follow-up vs. 82% in the patients without RFP (P < 0.001), and 52% in patients with left ventricular systolic dysfunction at follow-up vs. 75% in the patients with left ventricular ejection fraction of at least 50% (P = 0.001). Baseline predictors of death/transplantation were New York Heart Association class III-IV, indexed left atrial diameter, and RFP. When RFP and left ventricular systolic dysfunction were added at follow-up, both emerged as prognostic predictors (RFP: hazard ratio 8.92, 95% confidence interval 2.5-31.86; systolic dysfunction: hazard ratio 25.35, 95% confidence interval 3.57-179.88) with a significant increase of area under the receiver-operating characteristic curves (0.81 vs. 0.70, P = 0.03) with respect to the baseline model.

CONCLUSION

Left ventricular diastolic and/or systolic dysfunction at follow-up are relatively frequent in HCM and are associated with a poor prognosis.

Hypertrophic cardiomyopathy: from genetics to treatment

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is the prototypic form of pathological cardiac hypertrophy. HCM is an important cause of sudden cardiac death in the young and a major cause of morbidity in the elderly.

DESIGN

We discuss the clinical implications of recent advances in the molecular genetics of HCM.

RESULTS

The current diagnosis of HCM is neither adequately sensitive nor specific. Partial elucidation of the molecular genetic basis of HCM has raised interest in genetic-based diagnosis and management. Over a dozen causal genes have been identified. MYH7 and MYBPC3 mutations account for about 50% of cases. The remaining known causal genes are uncommon and some are rare. Advances in DNA sequencing techniques have made genetic screening practical. The difficulty, particularly in the sporadic cases and in small families, is to discern the causal from the non-causal variants. Overall, the causal mutations alone have limited implications in risk stratification and prognostication, as the clinical phenotype arises from complex and often non-linear interactions between various determinants.

CONCLUSIONS

The clinical phenotype of 'HCM' results from mutations in sarcomeric proteins and subsequent activation of multiple cellular constituents including signal transducers. We advocate that HCM, despite its current recognition and management as a single disease entity, involves multiple partially independent mechanisms, despite similarity in the ensuing phenotype. To treat HCM effectively, it is necessary to delineate the underlying fundamental mechanisms that govern the pathogenesis of the phenotype and apply these principles to the treatment of each subset of clinically recognized HCM.

Transesophageal pulsed Doppler echocardiographic evaluation of left atrial systolic performance in hypertrophic cardiomyopathy: combined analysis of transmitral and pulmonary venous flow velocities

BACKGROUND

Hypertrophic cardiomyopathy (HC) is characterized by impaired left ventricular (LV) diastolic function due to an increase in LV wall thickness. The severity of this disease varies depending on the localization and extent of the hypertrophied myocardium and the presence and extent of myocardial disarray or fibrosis.

HYPOTHESIS

The purpose of this study was to examine the background of hemodynamic abnormalities between the left atrium and the left ventricle during atrial systole in patients with HC using pulsed Doppler echocardiography.

METHODS

Hemodynamic abnormalities between the left atrium and left ventricle during atrial systole were evaluated in patients with HC using transmitral flow (TMF) and pulmonary venous flow (PVF) velocities obtained by transesophageal pulsed Doppler echocardiography. The study population included 50 patients with HC, including 39 with asymmetric septal hypertrophy and 11 with apical hypertrophy, and showing fractional shortening of the left ventricle > or = 30%. They were classified into three groups: (1) Group A (n = 11): the ratio of the late to early TMF velocity < 1, and peak atrial systolic PVF velocity (PVA) < 25 mm/s; (2) Group B (n = 13): their ratio < 1, and PVA > or = 25 mm/s; and (3) Group C (n = 26): their ratio > or = 1. The mean age of patients in Group A was lower than that in Groups B and C.

RESULTS

Left atrial dimension in Group B was significantly greater than that in the other HC groups and the control group. Furthermore, left atrial volume changes during atrial systole in Group B were significantly smaller than those in the other HC groups and the control group. Peak atrial systolic PVF velocity in Group B was significantly higher than that in the control group and in Group C. The duration of the atrial systolic waves of the TMF and PVF in Group B was significantly shorter and longer, respectively, than that in Group A. Left ventricular end-diastolic pressure (LVEDP) decreased in descending order with Group B > Group C > Group A. In all patients there was a significant positive correlation between the LVEDP and peak atrial systolic PVF velocity or the difference in duration between the atrial systolic waves of PVF and TMF. Plots of these values shifted toward the left and inferiorly in Group A, and toward the right and superiorly in Group B.

CONCLUSION

Peak velocity and duration of TMF and PVF during atrial systole by transesophageal pulsed Doppler echocardiography are useful indices of hemodynamic abnormalities between the left atrium and the left ventricle during atrial systole, particularly a forceful atrial contraction mismatched to the left atrial afterload and severity of LV diastolic dysfunction, in HC.

A-wave acceleration: a new Doppler echocardiographic index for evaluation of left ventricular diastolic dysfunction in elderly patients

Age alters Doppler indexes of left ventricular diastolic performance. Thus, the Doppler detection of left ventricular diastolic dysfunction in the elderly is difficult. The reliability of Doppler indexes in detecting left ventricular diastolic dysfunction in the elderly patients with cardiac diseases known to affect diastolic function were evaluated. Diastolic function using pulsed Doppler in 6 groups of 10 subjects each: elderly normal, young normal, and elderly with hypertrophic cardiomyopathy, aortic stenosis, coronary artery disease, and dilated cardiomyopathy was tested. The comparison of elderly normal with young normal showed that A-wave acceleration did not change significantly. Comparing elderly normal to elderly with diseases showed that all tested indexes except A-wave acceleration failed to separate normal elderly from diseased elderly. A-wave acceleration appears to be a useful index that can help in diagnosis of left ventricular diastolic dysfunction in elderly patients independent of age effects.

Left ventricular diastolic dysfunction in normotensive diabetic patients in various age strata

Although patients with type 2 diabetes demonstrate cardiac diastolic dysfunction, it is well known that cardiac diastolic dysfunction is produced by hypertension and aging. The purpose of the present study was to elucidate the cardiac structure and function in normotensive patients with type 2 diabetes in various age strata in order to assess the effect of diabetes mellitus itself on cardiac function. Echocardiographic examination was performed in 77 normotensive patients with type 2 diabetes (age: 63+/-11 years) and 76 healthy control subjects (age: 60+/-11 years) who were in their forties, fifties, sixties, and seventies. The left ventricular (LV) wall thickness and dimension were measured by M-mode echocardiography. The relative wall thickness, LV mass index, and LV ejection fraction (LVEF) were calculated. LV diastolic function was assessed by the peak velocity of early rapid filling (E velocity) and the peak velocity of atrial filling (A velocity), and the ratio of E to A (E/A) using the transmitral flow velocity, which were obtained by Doppler echocardiography. No difference was observed in the relative wall thickness, LV mass index, or LVEF between the diabetic patients and control subjects in any of the age strata. The E/A ratio in the patients with type 2 diabetes was not different from that in the control subjects in their 40s (1.17+/-0.35 versus 1.20+/-0.36). However, E/A was significantly lower in the diabetic patients than in the control subjects in their 50s (0.87+/-0.28 versus 1.14+/-0.24), 60s (0.78+/-0.22 versus 0.97+/-0.27), and 70s (0.66+/-0.19 versus 0.84+/-0.21) (p<0.05). The duration of type 2 diabetes was significantly longer in patients in their 50s (7.0+/-2.5 years), 60s (8.0+/-3.2 years), and 70s (10.4+/-3.2 years) than in patients in their 40s (3.3+/-1.9 years) (p<0.001). The value of E/A in the diabetic patients correlated with the duration of type 2 diabetes (r=-0.62, p<0.001). These results indicate that cardiac diastolic dysfunction without LV systolic dysfunction in patients with well-controlled type 2 diabetes is related neither to hypertension nor LV hypertrophy, but rather to aging and the duration of type 2 diabetes.

Cardiopulmonary responses of asthmatic children to exercise: analysis of systolic and diastolic cardiac function

The aim of this study was to evaluate aerobic exercise capacity, cardiac features and function in a group of asthmatic children who underwent medical treatment. Dynamic exercise testing was done to evaluate aerobic exercise capacity. Echocardiography was performed to identify the effects that asthma-induced pulmonary changes have on respiratory and cardiac function in these patients. The study involved 20 asthmatic children (aged 7-16 years) who were followed at our hospital and 20 age- and sex-matched, healthy control subjects. Sixteen of the asthma cases were moderate and four were severe. All 40 subjects underwent similar series of assessments: multiple modes of echocardiography, treadmill stress testing, pulmonary function testing. The means for forced expiratory volume in 1 sec, forced expiratory flow 25-75%, maximal voluntary ventilation and inspiratory capacity were all significantly higher in the control group. The patient group had significantly lower mean maximal oxygen uptake and mean endurance time than the controls but there were no significant differences between the groups with respect to respiratory exchange ratio or the ventilatory threshold. The control group means for ejection fraction, fractional shortening, left ventricular mass, and left ventricular mass index were significantly higher than the corresponding patient group results. Children with moderate or severe asthma have lower aerobic capacity than healthy children of the same age. The data suggest that most of these children have normal diastolic cardiac function, but exhibit impaired systolic function and have lower LVM than healthy peers of the same age.

Cardiac Function as Assessed by Echocardiography in the Oldest Old .GEQ. 90 Years of Age

Although several studies have demonstrated that cardiac diastolic function is impaired but cardiac systolic function is preserved with aging, no large-scale analysis of cardiac function by echocardiography in subjects aged > or = 90 years exists. The purpose of the present study was to elucidate the cardiac structure and function in the oldest old in order to assess the effect of aging on cardiac function. Echocardiographic examination was performed in 1793 subjects who were in their fifties, sixties, seventies, eighties, and nineties. Left ventricular (LV) wall thickness and dimension were measured by M-mode echocardiography. LV ejection fraction (LVEF) was calculated and used as the parameter representing LV systolic function. LV diastolic function was assessed using the peak velocity of early rapid filling (E velocity) and the peak velocity of atrial contraction (A velocity), and the ratio of E to A (E/A) by the transmitral flow. The Tei index, which reflects both LV diastolic and systolic function, was also calculated. The E/A decreased progressively with aging, and demonstrated the closest correlation with age among all the indexes of cardiac function (r = -0.44, P < 0.001). In contrast, LVEF and the Tei index demonstrated a very weak correlation with age (r = -0.13, P < 0.001 and r = 0.16, P < 0.001, respectively). The mean value for LVEF remained normal with aging in all age strata (50s: 71 +/- 8%, 60s: 71 +/- 8%, 70s: 70 +/- 9%, and 80s: 71 +/- 10%), but decreased significantly in subjects in their 90s (66 +/- 10%, P < 0.001). In addition, the mean value for the Tei index also remained normal with aging in subjects in their 50s (0.35 +/- 0.10), 60s (0.38 +/- 0.14), 70s (0.38 +/- 0.12), and 80s (0.39 +/- 0.15), but showed an abnormal value in subjects in their 90s (0.45 +/- 0.12, P < 0.001). In conclusion, both diastolic dysfunction and systolic dysfunction with advancing age were observed in the oldest old aged > or = 90 years. The age-related impairment of systolic function as well as diastolic function should be considered when echocardiography is used to evaluate the causes of heart failure in the oldest old.

Latent Cardiac Dysfunction as Assessed by Echocardiography in Bed-Bound Patients Following Cerebrovascular Accidents Comparison With Nutritional Status

The aim of this study was to elucidate the cardiac function in bed-bound patients following cerebrovascular accidents. In accord with the criteria for activities of daily living (ADL) of the Japanese Ministry of Health, Labour and Welfare, 51 age-matched poststroke patients without heart disease were classified into 3 groups: rank A (house-bound) (n = 16, age, 85 +/- 6 years), rank B (chair-bound) (n = 16, age, 84 +/- 8 years), and rank C (bed-bound) (n = 19, age, 85 +/- 9 years). Using echocardiography, the left ventricular (LV) diastolic function was assessed by the ratio of early filling (E) and atrial contraction (A) transmitral flow velocities (E/A) of LV inflow. LV systolic function was assessed by LV ejection fraction (LVEF), and the Tei index was also measured to assess both LV systolic and diastolic function. No difference was observed in the E/A and LVEF among the 3 groups. The Tei index was higher in rank C (0.56 +/- 0.17) than in rank A (0.39 +/- 0.06) and rank B (0.48 +/- 0.17), and a statistically significant difference was observed between rank A and rank C (P < 0.05). Serum albumin and blood hemoglobin were significantly lower in rank C (3.1 +/- 0.4 and 10.6 +/- 1.8 g/dL) than in rank A (4.1 +/- 0.3 and 12.4 +/- 1.2 g/dL) (P < 0.001 and P < 0.05, respectively). These results indicate that latent cardiac dysfunction and poor nutritional status may exist in bed-bound patients (rank C) following cerebrovascular accidents. The Tei index may be a useful index of cardiac dysfunction in bed-bound patients because it is independent of the cardiac loading condition.

Utility of a Doppler-derived index combining systolic and diastolic performance (Tei index) for detecting hypoxic cardiac damage in newborns

The purpose of this study was to assess cardiac function of newborns with mild asphyxia by a Doppler-derived index combining systolic and diastolic performance (Tei index). We studied 20 preterm infants with mild asphyxia. A control group consisted of 20 gestational age-matched preterm infants without asphyxia. Echocardiograms were performed during the fourth and seventh days after birth. Peak velocities of an early filling wave (E) and an atrial contraction wave (A) were measured from the mitral inflow velocity profile and the ratio of peak E to A was calculated. Ejection time was measured from the left ventricular outflow Doppler signal. The sum of isovolumetric times was obtained by subtracting the ejection time from the interval between cessation and onset of mitral inflow. The index was the sum of isovolumetric times divided by ejection time. Ejection fraction was also calculated. The ratio of peak E to A and ejection fraction were the same in both groups. The myocardial performance index in patients with asphyxia was higher than that in patients without asphyxia. We concluded that patients with mild asphyxia have a mild cardiac dysfunction and this change can be detected by a myocardial performance index.

Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with non-diagnostic echocardiography

OBJECTIVE

To investigate the role of cardiovascular magnetic resonance (CMR) in a series of patients with ECG repolarisation changes and normal echocardiography.

PATIENTS AND DESIGN

10 patients with anterolateral T wave inversion for which there was no obvious pathological cause who had normal routine echocardiography without contrast for the exclusion of hypertrophic cardiomyopathy (HCM) also had CMR that was diagnostic of apical HCM.

RESULTS

Apical HCM detected by CMR could be morphologically severe with wall thickness up to 28 mm, or mild. The extent of repolarisation abnormalities did not correlate to the morphological severity.

CONCLUSIONS

In patients with unexplained repolarisation abnormalities, a normal routine echocardiogram without contrast does not exclude apical HCM. Further imaging with CMR or contrast echocardiography may be required. The reliance on routine echocardiography to exclude apical HCM may have led to underreporting of this condition.

Prediction of heart failure post myocardial infarction: comparison of ejection fraction, transmitral filling parameters, and the index of myocardial performance

Following an acute myocardial infarction (MI), the development of congestive heart failure (CHF) has been associated with a reduced ejection fraction (EF), pseudonormal or restrictive diastolic filling, and an increased index of myocardial performance (IMP).

STUDY OBJECTIVES

To determine the comparative predictive value of EF, transmitral filling parameters, and IMP for the development of CHF following a first MI.

DESIGN AND SETTING

A retrospective analysis of consecutive echocardiographic and Doppler studies in patients admitted for their first acute MI from the years 1988 through 1992. We studied 109 patients following their first MI with two-dimensional and Doppler within 24 hours of MI. We divided patients into those who developed CHF within 15 days (43 patients) and without CHF (66 patients).

RESULTS

Patients who developed CHF had greater LV dilatation, lower EF (27.7%+/- 10.2% vs 45.6%+/- 13.2%, P < 0.001), higher E/A, shorter deceleration times (DCT; 157 +/- 69 msec vs 248 +/- 105 msec, P < 0.001), and increased IMP. Utilizing multiple logistic regression, EF (strongest predictor), DCT, and IMP were predictive of CHF. Nineteen patients in the no CHF group developed late CHF and had lower EFs (30.5%+/- 13.1% vs 50.5%+/- 9.8%, P < 0.001), higher E/A and shorter DCTs (161 +/- 39 msec vs 283 +/- 103 msec, P < 0.001). EF, DCT, and E/A were predictive of late CHF in patients without initial CHF. For patients admitted with a first MI, the EF, DCT, and to a lesser extent IMP predicted who would ultimately develop CHF. An EF < 40% or a DCT < 200 msec correctly predicted CHF in 60 of 62 patients.

CONCLUSION

We conclude that the early and ultimate development of CHF following a first MI were associated with an moderately reduced EF < 40%, pseudonormal diastolic filling indices, and an increased IMP.

[Diagnosis and therapeutic guidance of diastolic heart failure]

Despite diastolic dysfunction is recognized to play a major role in the pathophysiology of heart failure, the importance of an accurate diagnosis and treatment of this syndrome in clinical practice is poorly established. Recent publications suggest that diastolic dysfunction is the primary cause of heart failure in 30-50% of patients. Several studies also show that, in a significant number of patients with systolic dysfunction, diastolic function is the major determinant of their symptomatic status, their response to treatment and their outcome. Other preliminary data suggest that diastolic dysfunction is an important cause of exercise intolerance in patients with chronic hypertension. This paper discusses the most recent concepts related to the mechanisms, the diagnosis and the treatment of diastolic dysfunction based on diagnostic imaging techniques.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Myocardial perfusion SPECT and isotopic ventriculography in obstructive and non-obstructive hypertrophic myocardiopathy]

OBJECTIVE

To evaluate the role of myocardial perfusion SPET and radionuclide ventriculography in patients with hypertrophic cardiomyopathy (HC).

METHODS

Exercise myocardial perfusion SPET with 99mTc-tetrofosmin and radionuclide ventriculography were performed in a consecutive series of 101 patients (54 15 years, 50 women, 55 with dynamic obstruction) diagnosed of HC by echo. Follow-up from the diagnosis was 9,9 6,7 years (1 to 28 years).

RESULTS

Thirty six percent of patients had perfusion defects (non reversible in 15 and reversible in 21). In non obstructive HC higher number of patients with non reversible defects (p = 0.01 was obseved and in patients with no reversible defects higher incidence of pathologic Q waves in ECG (p = 0.01), Higher ventricular volumes (p < 0.05), lower ejection fraction (p = 0,0001) and longer time to peak emptying velocity (p < 0.05). There were 4 cardiac deaths, 15 syncopes, 18 pacemakers and 6 myectomy. Ejection fraction was higher in patients with syncope (p = 0,034) and there was no isotopic variable predictive of mortality, pacemaker or myectomy.

CONCLUSIONS

Neither SPET nor radionuclide ventriculography have a prognostic role in patients with HC, but patients with syncope have higher values of ejection fraction. Patients with non reversible defects have higher rate of pathologic Q waves in ECG, higher ventricular volumes and lower ejection fraction. This is indicative of evolution to dilated form of HC.

Usefulness of early diastolic flow propagation velocity measured by color M-mode Doppler technique for the assessment of left ventricular diastolic function in patients with hypertrophic cardiomyopathy

Flow propagation velocity (FPV) of left ventricular (LV) filling flow has been shown to be a useful index for the evaluation of LV diastolic function, which is relatively independent of preload in myocardial infarction and dilated cardiomyopathy, but the usefulness of FPV for hypertrophic cardiomyopathy (HCM) has not yet been determined. In 23 HCM patients and 26 control subjects, peak transmitral flow velocities in early diastole (E) and during atrial contraction (A), E/A ratio, deceleration time of E velocity, and isovolumic relaxation time were measured with the conventional Doppler technique, and FPV was measured from color M-mode Doppler images of LV filling flow. The time constant of LV isovolumic pressure decay (tau) was measured by a micro-manometer-tipped catheter in all HCM patients and 13 control subjects. Flow propagation velocity was significantly lower and deceleration time was significantly greater in HCM patients than in the control subjects, though no significant differences were observed in the other noninvasive indexes. Tau was significantly prolonged in HCM patients compared with that of control subjects (54+/-12 cm/s and 32 +/-7 cm/s, respectively; P<.0001). While the conventional indexes did not correlate with tau among the 36 patients in whom invasive studies were performed, FPV correlated well with tau (r = -0.76, P<.0001). Flow propagation velocity is a useful noninvasive index for the assessment of LV diastolic function in patients with HCM.

Assessment of the Systolic Left Ventricular Myocardial Velocity Profile and Gradient Using Tissue Doppler Imaging in Patients with Hypertrophic Cardiomyopathy

To determine the systolic characteristics of the hypertrophied myocardium in patients with hypertrophic cardiomyopathy (HCM), we evaluated the left ventricular [left ventricle (LV)] myocardial velocity profile (MVP) and gradient obtained from tissue Doppler imaging (TDI). Transmural wall-motion velocities in the ventricular septum and LV posterior wall were recorded in 12 patients with asymmetric septal hypertrophy and 12 healthy volunteers, and their profiles and gradients were determined. The maximum systolic myocardial velocity gradient in the ventricular septum was significantly lower in the HCM group than in the control group (0.88 +/- 0.35 versus 2.24 +/- 0.41; P < 0.001), whereas the gradient in the LV posterior wall was only slightly lower in the HCM group than in the control group (2.69 +/- 0.82 versus 3.45 +/- 0.96). In the control group, the MVPs in the ventricular septum and LV posterior wall were closely linear, suggesting that the transmural velocity is uniform during systole. MVPs in the ventricular septum and LV posterior wall in the HCM group also were closely linear, whereas the distribution of velocities in the ventricular septum was fairly dispersed compared with the control group. The myocardial velocity gradient on the right ventricular side of the ventricular septum decreased or disappeared in the patients with HCM, suggesting a nonuniform distribution of velocities. In conclusion, the MVP and gradient obtained from TDI may represent new indices for evaluating regional LV contractile abnormality in patients with HCM.

Comparison of usefulness between exercise capacity and echocardiographic indexes of left ventricular function in cardiac amyloidosis

In patients with primary systemic amyloidosis (AL), the echocardiographic assessment of ventricular function alone does not always correspond to patients' symptoms and functional status. Peak oxygen uptake and anaerobic threshold (AT), in contrast, constitute 2 objective, reliable and reproducible indicators of functional status in patients with circulatory failure. Thirty-two consecutive patients (mean age 50 +/- 13 years) with histologic evidence of systemic primary AL were studied (29 AL, 3 hereditary). There were 16 with echocardiographic features of cardiac infiltration (group I) and 16 without (group II). Twenty age- and gender-matched healthy subjects were also studied for comparison. Of the 32 patients, 12 were in New York Heart Association functional class I, 9 were in class II, and 11 were in class III. Each subject underwent 2-dimensional and Doppler echocardiography and cardiopulmonary exercise testing using a modified Bruce protocol. Left atrial (LA), left ventricular (LV) dimensions, wall thickness, and LV fractional shortening, as well as transmitral flow velocities and their E/A ratio were measured. Peak oxygen consumption (VO2max [ml/kg/min]), AT (ml/kg/min), and exercise duration (seconds) were also measured. VO2max and AT were lower in patients with AL than in controls (20.8 +/- 7.0 vs 35.0 +/- 8.5, p <0.001 and 13.1 +/- 3.7 vs 27.0 +/- 4.2, p <0.001, respectively). As a group, symptomatic patients had lower VO2max, AT, and exercise duration than those without symptoms (17.1 +/- 3.6 vs 27.0 +/- 6.9, p = 0.0001, 11.1 +/- 2.1 vs 16.2 +/- 3.6, p = 0.0001, and 489 +/- 235 vs 843 +/- 197, p = 0.0001, respectively), whereas LV dimensions only showed a small difference (p = 0.03). VO2max, AT, and exercise duration of patients in functional class I were higher than those in functional classes II and III (p = 0.01, p <0.05, and p = 0.007, respectively). Asymptomatic patients had lower VO2max, AT, and exercise duration than controls (p <0.0001). VO2max, AT, and exercise duration were poorly related to LA diameter, LV dimensions, fractional shortening, wall thickness, peak velocities of E and A waveforms, and E/A ratio. Patients with VO2max > 15 ml/kg/min had a better survival than patients with VO2max < 15 ml/kg/min. Thus, in patients with primary systemic AL, cardiorespiratory exercise testing is the preferred way of assessing functional capacity. Echocardiographic Doppler indexes at rest are not predictive of a patient's symptoms and exercise capacity. Furthermore, VO2max is a strong independent predictor of survival in these patients.

Effects of posture on left ventricular diastolic filling during exercise

BACKGROUND

Measuring the transmitral flow velocity with Doppler echocardiography is a useful method for evaluating left ventricular diastolic function. However, there are few data regarding the effect of posture during exercise on transmitral flow velocity.

METHODS

The transmitral flow velocity with pulsed-wave Doppler echocardiography was measured during supine and upright bicycle ergometer exercise in 10 normal young men without cardiac disease (26.7 +/- 5.5 yr).

RESULTS

The ratio of the early rapid filling wave to the atrial filling wave (E/A) was gradually decreased with increasing exercise intensity. At rest and during recovery, the E/A ratio was significantly higher (P < 0.01) in the supine position than in the upright position. This difference was caused mainly by the higher E wave in the supine position. However, E wave and E/A ratio did not differ between the upright and supine position during exercise.

CONCLUSION

Although measurement of left ventricular filling is completely noninvasive and clinically useful for evaluating diastolic function, it was found that the E/A ratio was profoundly influenced by posture and exercise intensity. These results suggest that the potential influences of posture and exercise intensity on the filling velocities should be taken into account when interpreting diastolic function by Doppler echocardiography.

Effect of positive end-expiratory pressure on left and right ventricular diastolic filling assessed by transoesophageal Doppler echocardiography

The effect of positive end-expiratory pressure (PEEP) on left and right ventricular diastolic filling dynamics was assessed by transmitral and transtricuspid flow patterns. Using transoesophageal Doppler echocardiography in fourteen ASA physical status 1 female patients, the following measurements were performed at baseline (0 cm H2O PEEP) and at 5, 10, 15, and 20 cm H2O PEEP: 1. peak velocity of early filling (peak E velocity), 2. peak velocity of atrial contraction (peak A velocity), 3. the ratio of the peak E to A velocity (peak E/A velocity ratio), 4. isovolumic relaxation time (IRT), 5. acceleration half-time (AHT), 6. deceleration half-time (DHT) of early filling, and 7. end-diastolic and end-systolic areas of both ventricles. Increasing PEEP progressively deceased peak E velocity of both ventricles. In contrast, peak A velocity did not change and the peak E/A velocity ratio decreased significantly with PEEP. IRT and AHTs remained unchanged, but DHTs of both ventricles increased following PEEP. End-diastolic and end-systolic areas of both ventricles decreased gradually and significantly with PEEP. It is concluded that PEEP was associated with decreased preload as well as reduced compliance of both ventricles, which was considered to contribute to the changes in diastolic ventricular filling.

Differentiation of abnormal relaxation pattern with aging from abnormal relaxation pattern with coronary artery disease in transmitral flow with the use of tissue Doppler imaging of the mitral annulus

An abnormal relaxation pattern in transmitral flow velocity waveforms has been observed in older healthy subjects as well as in patients with heart disease. Accordingly, we investigated whether the hemodynamic differences between patients with coronary artery disease (CAD) with an abnormal relaxation pattern in transmitral flow (ratio of E-wave to A-wave velocities < 1.0) and healthy older subjects with an abnormal relaxation pattern can be distinguished with the use of mitral annular velocity (MAV) during early diastole. We measured MAV in the longitudinal direction of the heart during early diastole by M-mode color tissue Doppler imaging in 24 patients with atypical chest pain (defined as healthy subjects in this study) and 70 patients with CAD who underwent cardiac catheterization. In all patients a time constant of left ventricular pressure decay (tau) and the left ventricular (LV) end-systolic volume index were also measured. Twenty-one healthy subjects and 59 patients with CAD had an abnormal relaxation pattern in their transmitral flow. The age, heart rate, mean blood pressure, and ratio of E-wave to A-wave velocities were not different between the two groups. However, the tau was longer and the LV end-systolic volume index was greater in patients who had an abnormal relaxation pattern with CAD than in healthy subjects with an abnormal relaxation pattern. The MAV during early diastole was lower in the former than in the latter (5.8 +/- 1. 9 vs 9.8 +/- 1.9 cm/s, P <.001). Mitral annular velocity during early diastole by M-mode color tissue Doppler imaging can detect the differences in LV relaxation and LV systolic performance between the abnormal relaxation pattern with CAD and the physiologically abnormal relaxation pattern with aging, providing further information regarding the meaning of an LV abnormal relaxation pattern.

Color M-mode Doppler flow propagation velocity is a relatively preload-independent index of left ventricular filling

Standard Doppler indexes of transmitral filling vary in response to alterations in left ventricular (LV) relaxation or preload. To determine whether color M-mode Doppler flow propagation velocity (vp), a new index of LV relaxation, is affected by preload, we obtained LV volumes, standard Doppler filling indexes, and vp in 20 patients at baseline, during Trendelenburg's position, inverse Trendelenburg's position, and after inhalation of amyl nitrite. LV end-diastolic volume decreased from 111 +/- 41 mL at baseline and 116 +/- 43 mL during Trendelenburg's position, to 104 +/- 40 during inverse Trendelenburg's maneuver and 92 +/- 33 mL after inhalation of amyl nitrite (P <.0001). Peak early filling velocity decreased from 79 +/- 19 cm/s and 90 +/- 20 cm/s to 73 +/- 22 cm/s and 64 +/- 20 cm/s, respectively (P < 0.0001). In contrast, no significant changes were found in vp (48 +/- 24 and 50 +/- 26 cm/s vs 48 +/- 25 and 48 +/- 25 cm/s). We conclude that vp is not affected significantly by preload. Thus vp may provide a more reliable and independent assessment of LV relaxation.

Change in cardiac diastolic function in neonates

In this study we used Doppler echocardiography to examine changes in ventricular diastolic function in neonates. Echocardiograms were performed in 25 healthy neonates at 1-6 days (2.7+/-1.6 days) and at 25-35 days (29.4+/-3.3 days) after birth. Ventricular inflow velocity curves were recorded using the pulsed-Doppler method. Peak velocities (peak E, A). mean velocities (mean E, A), times (time E, A), and diastolic velocity-time integrals (area E, A) were measured during both early ventricular filling and atrial systole. The acceleration time of the wave during early ventricular filling was also measured. Peak E and A and mean E and A in both ventricles increased at 1 month after birth. Acceleration times in both ventricles were shortened. The ratio of area E to A in both ventricles and of peak E to A in the left ventricle did not change at 1 month after birth. Only the ratio of peak E to A in the right ventricle increased. The ratio of peak E to (area E + area A), which is thought to be a load-independent index, increased in both ventricles. The authors concluded that ventricular relaxation appears to increase in both ventricles, 1 month after birth, and that changes in diastolic function occur even in neonates.

Use of pulsed Doppler tissue imaging to assess regional left ventricular diastolic dysfunction in hypertrophic cardiomyopathy

In this study, regional diastolic patterns and their relations with transmitral Doppler inflow were investigated in hypertrophic cardiomyopathy (HC) by pulsed Doppler tissue imaging (DTI). Doppler echocardiography and DTI of basal septum and lateral wall (apical 4-chamber view) were performed in 20 patients (15 men and 5 women) with HC and in 10 healthy subjects (7 men and 3 women). Diabetes, hypertension, coronary artery and valvular disease, mitral regurgitation, New York Heart Association functional classes III to IV, sinus tachycardia, atrial fibrillation, and inadequate echocardiograms were exclusion criteria. Peak velocity and time-velocity integral of early and late waves and their ratios, and deceleration and isovolumic relaxation times were determined by standard Doppler and by DTI at the septal and lateral wall levels. The 2 groups were comparable for age, heart rate, blood pressure, and ejection fraction. Transmitral peak velocity and time-velocity integral E/A ratios were reduced (both p <0.05) and deceleration and isovolumic relaxation times prolonged (both p <0.00001) in HC. Septal DTI showed lower peak velocity and time-velocity integral e/a ratios (p <0.00001 and p <0.001, respectively) and lengthened regional deceleration (p <0.01) and isovolumic (p <0.001) relaxation times. DTI of the lateral wall showed a prolongation of deceleration and isovolumic relaxation times (both p <0.01). By dividing HC according to transmitral E/A, 8 patients with E/A <1 had lower DTI septal e/a ratio (p <0.01) and prolonged septal deceleration and isovolumic relaxation times (both p <0.01) but no changes in DTI pattern of lateral wall than 12 patients with E/A > 1. In conclusion, DTI is useful and complementary to standard Doppler imaging to characterize diastolic properties in HC, reflecting a typical pattern of intramyocardial impaired relaxation at the level of hypertrophied septum and also providing information about the degree of this regional impairment. The lateral wall presents minor changes in diastolic times, which indicate how diastolic asynchrony is not confined to the hypertrophied segment in HC.

Doppler echocardiographic study of left ventricular diastole in non-anaesthetized healthy cats

The current study: (1) describes the Doppler technique for the assessment of diastolic function in feline patients; (2) reports normal Doppler diastolic values; and (3) determines the effect of ageing on these parameters. Doppler echocardiography was performed on 20 non-anaesthetized healthy cats. Each diastolic parameter was correlated with age, body weight, body surface area and R-R interval. To assess the isovolumetric relaxation phase of diastole, isovolumetric relaxation time was measured. To assess the filling phase of diastole, we measured peak flow velocities of the E and A waves, diastolic filling time, acceleration and deceleration time of the E wave and the E/A ratio of transmitral flow, peak flow velocity of the S, D and the A retrograde waves, as well as the S/D ratio and the systolic fraction of pulmonary venous flow. We found a significant correlation between age and peak flow velocity of the A wave, normalized peak flow velocity of the A wave, the E/A ratio, the acceleration time of the E wave, the diastolic filling time, the velocity time integral of the E wave, the peak flow velocity of the S wave and the systolic fraction. It was concluded that Doppler echocardiographic analysis of diastole is possible in the cat and that age has most effect on filling parameters.

Left ventricular diastolic filling in the elderly: the cardiovascular health study

Changes in left ventricular (LV) diastolic function (e.g., as measured by transmitral flow velocity) are known to occur with aging. In addition, impaired LV diastolic function plays an important role in such cardiovascular disorders common in the elderly as hypertension, ischemic heart disease, and congestive heart failure (CHF). Participants in the Cardiovascular Health Study, a multicenter study of community-dwelling men (n=2,239) and women (n=2,962) > or = 65 years of age, underwent an extensive baseline evaluation, including echocardiography. Early diastolic LV Doppler (transmitral) peak filling velocity decreased, and peak late diastolic (atrial) velocity increased with age in multivariate analyses (all p <0.001). Early and late diastolic peak filling velocities were both significantly higher in women than in men, even after adjustment for body surface area (or height and weight). In multivariate models in the entire cohort and a healthy subgroup (n=703), gender, age, heart rate, and blood pressure (BP) were most strongly related to early and late diastolic transmitral peak velocities. Early and late diastolic peak velocities both increased with increases in systolic BP and decreased with increases in diastolic BP (p <0.001). Doppler transmitral velocities were compared among health status subgroups. In multiple regression models adjusted for other covariates, and in analysis of variance models examining differences across subgroups adjusted only for age, the subgroup with CHF had the highest early diastolic peak velocities. All clinical disease subgroups had higher late diastolic peak velocities than the healthy subgroup, with the subgroups with either CHF or hypertension having the highest age-adjusted means. The subgroup with hypertension had the lowest ratio of early-to-late diastolic peak velocity, and men with CHF had the highest ratio. These findings are consistent with previous reports that hypertensive subjects exhibit an abnormal relaxation pattern, whereas patients with CHF develop a pattern suggestive of an increased early diastolic left atrial-LV pressure gradient.

Rates of left ventricular isovolumic pressure rise and fall from the aortic regurgitation velocity signal: description of the method and validation in human beings

BACKGROUND

Aortic regurgitation results from a pressure gradient across the aortic valve during left ventricular (LV) isovolumic relaxation, LV filling, and isovolumic contraction periods. Assuming the applicability of the simplified Bernoulli equation to this pressure-flow relation and constancy of aortic pressure during LV isovolumic relaxation and contraction periods, one can theoretically obtain estimates of the rates of LV isovolumic pressure fall and rise (deltaP/delta t) from the aortic regurgitation (AR) velocity signal.

METHODS AND RESULTS

Mitral regurgitation (MR) and AR signals were recorded by using the continuous wave Doppler technique in 26 patients with combined mitral and aortic regurgitant lesions. The LV negative deltaP/delta t was obtained by dividing the time taken for the AR velocity to rise from 1 m/sec to 2.5 m/sec into 21 mm Hg, which is the estimated LV pressure drop between these points. In a similar fashion, the LV positive deltaP/delta t was obtained between 2.5 m/sec and 1 m/sec of the fast decelerating portion of the AR signal. The LV negative deltaP/delta t by the AR method ranged from 420 to 3500 mm Hg/sec and correlated well with that obtained by the MR method obtained in a blinded fashion (r = 0.95, p < 0.0001). The mean (SD) difference between the two methods was 30 (129) mm Hg/sec. Similarly, the LV positive deltaP/delta t by the AR method (range 420 to 2625 mm Hg/sec) correlated closely with that obtained by the MR method (r = 0.93, p < 0.0001), with the mean (SD) difference between the two methods being 38 (138) mm Hg/sec.

CONCLUSIONS

Preliminary data presented in this study indicate the feasibility of obtaining a reliable estimate of LV positive and negative deltaP/delta t from the AR velocity profile. Thus the examination of the AR signal may give valuable insights into both LV systolic and diastolic functions.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography

Left ventricular diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. An impaired relaxation pattern identifies patients with early stages of heart disease, and appropriate therapy may avert progression and functional disability. Pseudonormalization is a transitional phase between abnormal relaxation and restrictive physiology and signifies increased filling pressure and decreased compliance. In this phase, reducing preload, optimizing afterload, and treating the underlying disease are clinically helpful. A restrictive physiology pattern identifies advanced, usually symptomatic disease with a poor prognosis. Therapeutic intervention is directed toward normalizing loading conditions and improving the restrictive filling pattern, although this may not be feasible in certain heart diseases. Finally, many patients have left ventricular filling patterns that appear indeterminate or mixed. In these cases, clinical information, left atrial and left ventricular size, pulmonary venous flow velocity, and alteration of preload help assess diastolic function and estimate diastolic filling pressures.

Apical hypertrophic cardiomyopathy: a study of 14 patients and their first degree relatives

Although apical hypertrophic cardiomyopathy is generally accepted as a form of hypertrophic cardiomyopathy, its underlying genetic factors, clinical course and complications may be different. The characteristics of 14 Brazilian patients with a diagnosis of apical hypertrophic cardiomyopathy are described. Symptoms were frequent and abnormal filling of the left ventricle by Doppler criteria was recorded in all patients. Rest electrocardiograms showed giant negative T waves in 5 patients, all had low exercise capacity on an exercise stress test while significant arrhythmias were detected by 24-h ambulatory monitoring in just one patient. Forty-eight first degree relatives were studied and 3 had some form of hypertrophy of the left ventricle as seen by echocardiography. Apical hypertrophic cardiomyopathy in Brazilians seems to be expressed somewhat differently from that reported in Japanese patients, since "giant' T waves are less frequent and women more involved.

'Abnormal' diastolic Doppler patterns in patients over age 65 with severe left ventricular systolic dysfunction

OBJECTIVE

The purpose of this study was to determine whether Doppler diastolic filling patterns of the left ventricle are altered in patients over age 65 with poor left ventricular function, compared to patients with normal left ventricular systolic function.

BACKGROUND

In elderly, healthy subjects, the mitral valve Doppler inflow pattern exhibits an increase in atrial contribution to left ventricular filling. Myocardial disease, which results in stiffness, may also cause an increase in A wave velocity.

METHODS

Twenty-seven patients over age 65, with left ventricular systolic dysfunction, were age and sex-matched with 19 patients with normal left ventricular systolic function. Patients with significant mitral or aortic valvular disease were excluded. Maximal early inflow velocity, maximal atrial inflow velocity, heart rate, acceleration time and deceleration time were calculated.

RESULTS

Comparing the group with normal left ventricular systolic function, the group with decreased left ventricular systolic function had pseudonormalization of the maximal early flow/atrial flow velocity ratio (1.7 +/- 1.3 vs. 0.9 +/- 0.3; P = 0.003), E wave velocity was similar (82 +/- 28 vs. 70 +/- 24 cm/s; P = n.s.), and A wave velocity was diminished (66 +/- 30 vs. 84 +/- 20 cm/s; P = 0.02). The acceleration time was similar for the groups (53 +/- 17 vs. 46 +/- 21 ms), but the deceleration time was shorter in patients with left ventricular systolic dysfunction (122 +/- 33 vs. 192 +/- 80 ms; P < 0.001).

CONCLUSION

Such differences may relate to increased left atrial pressure, increased left ventricular diastolic pressure and/or decreased atrial systolic function. These findings are important when interpreting left ventricular filling indices by Doppler echocardiography in elderly patients.

Plasma atrial natriuretic peptide is elevated in patients with hypertrophic cardiomyopathy

STUDY OBJECTIVES

To determine if plasma levels of atrial natriuretic peptide are elevated in patients with hypertrophic cardiomyopathy and to determine the relationship of atrial natriuretic peptide to symptoms and echocardiographic indices of left ventricular structure and diastolic function in these patients.

DESIGN

A prospective study in which atrial natriuretic peptide was measured in peripheral venous plasma in 14 patients (age 44 +/- 14 years) with hypertrophic cardiomyopathy and 17 healthy controls. Echocardiography was performed in all cases and 30 controls to examine indices of left heart structure and function. All patients underwent clinical evaluation.

RESULTS

The concentration of atrial natriuretic peptide was significantly higher in patients with hypertrophic cardiomyopathy than controls, (17.86 +/- 8.72 vs. 6.22 +/- 3.26 pmol/l, P = 0.0001). Diastolic dysfunction was observed in 11 of 14 patients with hypertrophic cardiomyopathy. No correlation was demonstrated between atrial natriuretic peptide levels and the degree of diastolic dysfunction, septal or free wall thickness, left atrial size, degree of mitral regurgitation or New York Heart Association functional class.

CONCLUSIONS

Plasma levels of atrial natriuretic peptide are elevated in patients with hypertrophic cardiomyopathy but do not correlate with symptoms or echocardiographically-derived indices of left ventricular structure or diastolic function.

Cardiovascular function during rest and exercise in patients with sickle-cell anemia and coexisting alpha thalassemia-2

Cardiac function was measured at rest and during exercise in 9 patients with sickle-cell anemia (SS) and coexisting homozygous alpha thalassemia-2 (alpha thal-2). Results were compared with 18 sickle cell patients with normal alpha globin genes, who were matched to the study group by age, gender, and size, and to published normal values. SS alpha thal-2 patients were less anemic: 9.9 +/- 1.0 vs 8.2 +/- 1.2 gm/dl for SS alone (P<.05). Left ventricular dimensions were normal in SS alpha thal-2 (4.9 +/- 0.7 cm), but increased in SS (5.4 +/- 0.7, cm P=.05) (normal range, 3.7-5.6 cm). Left ventricular wall thickness was, however, dramatically increased in the SS alpha thal-2 patients (free wall, 1.8 +/- 0.6 cm; septum, 1.6 +/- 0.4 cm), though SS controls had normal wall thickness (free wall, 1.0 +/- 0.2 cm; septum, 1.0 +/- 0.2 cm, P<.001) (normal range, 0.6-1.1 cm). At rest, Doppler indices of systolic function were not significantly different between sickle groups and normal values. SS alpha thal-2 patients did have abnormal diastolic filling at rest, as evidenced by a reduced ratio of early/late diastolic filling, 1.4 +/- 0.3 vs. 2.0 +/- 0.5 for SS controls (P<.01), and 1.8 +/- 0.4 for normals. An analysis of covariance suggested that this abnormality persisted after taking into account the previously demonstrated hypertrophy. During exercise, SS alpha thal-2 patients had higher heart rates and blood pressures than SS controls in spite of performing the same or less work. This resulted in a higher double product (an estimate of oxygen consumption) in SS alpha thal-2 patients (37,470 +/- 2,310 mm Hg-BPM) than in SS controls (33,310 +/- 1,490 mm Hg-BPM, P<.01). Work capacity, peak heart rate, and blood pressure were all abnormally decreased in both sickle-cell groups when compared to normal. Cardiac abnormalities noted at rest and during exercise in SS alpha thal-2 patients suggest a role of microvascular occlusion and a protective effect of decreased hemoglobin.

Newer Doppler measures of left ventricular diastolic function

Left ventricular (LV) diastolic dysfunction is an important cause of heart failure, and recent advances in the application of Doppler techniques allow a semiquantitative assessment of LV diastolic performance. This review discusses the use of Doppler echocardiography in the comprehensive assessment of LV diastolic function and performance in terms of the normal mitral and pulmonary venous flow profiles, their physiologic basis, and alterations in diseased states. There is also a discussion on the newer aspects of mitral flows such as relative durations of mitral A and pulmonary vein AR waves, E- and A- wave propagation inside the LV with their hemodynamic correlates, and derivation of ventricular dP/dt and Tau from the mitral regurgitation velocity profile. Analysis of these flow profiles and the other Doppler measures alluded to above allow one to make a fairly precise hemodynamic assessment of a patient in terms of left atrial pressure, LV relaxation and stiffness and the profile of LV diastolic pressure in terms of pre- 'a' wave and 'a' wave pressures and ventricular end-diastolic pressure.

Left ventricular filling pattern in uncomplicated obesity

To determine if uncomplicated obesity is associated with systolic dysfunction or impairment of left ventricular (LV) filling, 40 normotensive, white, asymptomatic, obese subjects (16 men and 24 women, mean +/- SD age 35 +/- 13 years; body mass index 36 +/- 6 kg/m2) and 40 normotensive, normal-weight, white volunteers matched for age and sex distribution, were studied by Doppler echocardiography. Endocardial and midwall shortening did not show differences between groups (obese = 33 +/- 4% and 17 +/- 2%; normal weight = 33 +/- 3% and 18 +/- 2%, respectively). LV mass index was higher in obese than in normal-weight subjects (p <0.0001). Obese persons had prolonged isovolumic relaxation time (p <0.0001), lower transmitral peak early diastolic filling wave (E) velocity (p <0.02), higher E velocity deceleration time (p <0.002) and lower E/atrial diastolic filling wave (A) flow velocity ratio (p <0.01) than did normal-weight subjects, even after controlling for age and blood pressure. Between-group differences in E and E velocity deceleration time disappeared when controlling for LV mass index, whereas prolonged isovolumic relaxation time in obesity was independent of LV mass, chamber dimension, and end-systolic stress. LV filling variables were not statistically related to endocardial or midwall shortening, both as absolute value or as a percentage of that predicted from wall stress. We conclude that uncomplicated obesity is associated with primary impairment of LV isovolumic relaxation; abnormalities of early passive filling flow in obesity are associated with increased LV mass.

Doppler diastolic filling indexes in relation to disease states

This study compares mean Doppler-derived diastolic filling indexes in a variety of disease states in a large, population-based sample. Pulse-wave Doppler was used to examine 880 eligible participants of the Framingham Heart Study. Peak velocity of early flow and late flow, ratio of early to late peak velocities, atrial filling fraction, and early filling wave acceleration and deceleration times were obtained. Multiple linear regression analyses were performed comparing mean values for individuals with hypertension, diabetes, coronary disease, cardiovascular disease, and pulmonary disease. Hypertension was associated with a greater peak velocity late flow (0.027 m/sec; 95% confidence interval, 0.006, 0.047; p = 0.011), and diabetes was associated with a larger mean deceleration time (0.12 sec, confidence interval, 0.002, 0.021; p = 0.016). In multivariate analyses, hypertension continued to show a strong association with altered Doppler diastolic filling patterns, p value 0.009, whereas in diabetes, the multivariate p value was 0.28.

Influence of left atrial function on Doppler transmitral and pulmonary venous flow patterns in dilated and hypertrophic cardiomyopathy: evaluation of left atrial appendage function by transesophageal echocardiography

Information regarding the relation of left atrial (LA) function to transmitral and pulmonary venous (PV) flow is limited. Using transesophageal echocardiography, we analyzed this relation in 23 patients with dilated cardiomyopathy (DCM) and 25 patients with hypertrophic cardiomyopathy (HCM). Left atrial appendage (LAA) function was assessed as a substitute for overall LA function. Transmitral and PV flow-velocity variables, the LAA emptying flow velocity (LAA-A), and the LAA ejection fraction (LAA-EF) were determined. Each patient group was divided into two subgroups with a normal ( < 15 mm Hg) or elevated ( > or = 15 mm Hg) mean pulmonary wedge pressure (PWP). Transmitral and PV flow patterns as well as LA function were similar in the two subgroups with a normal PWP (11 patients with DCM and 14 patients with HCM). For the subgroups with an elevated PWP, however, the peak velocity ratio of the early filling wave (E) to atrial contraction wave (A) was higher in DCM patients (n = 12) than in HCM patients (n = 11) (2.1 +/- 0.7 vs 1.3 +/- 0.2; p < 0.01). This difference mostly resulted from a lower A velocity in the DCM group than in the HCM group (30 +/- 10 cm/sec vs 43 +/- 7 cm/sec; p < 0.05). In addition, the reverse flow velocity at atrial contraction in the PV was lower in the DCM group than in the HCM group (19 +/- 8 cm/sec vs 37 +/- 8 cm/sec; p < 0.01). These findings were associated with poorer LA systolic function in the DCM group (LAA-A, 35 +/- 13 cm/sec vs 60 +/- 11 cm/sec; LAA-EF, 37% +/- 12% vs 55% +/- 15%, p < 0.05, respectively). Our data suggest that a restrictive transmitral flow pattern develops more easily in DCM than in HCM because LA dysfunction is present in DCM, and that LA contractility plays an important role in determining the atrial contraction wave of transmitral and PV flows with elevated LA pressure.

Pulmonary venous flow as assessed by Doppler echocardiography: potential clinical applications

During the past few years Doppler assessment of pulmonary venous flow has gained increasing interest. The growing experience with the use of transesophageal echocardiography, the approach that nearly always yields registrations adequate for quantitative analysis, has markedly contributed in this respect. The Doppler-derived pulmonary venous flow pattern can be regarded as a measure of left atrial inflow and it augments the clinical significance of Doppler transmitral flow in the evaluation of diastolic left ventricular function. This article summarizes physiological background, possible applications, and limitations of Doppler echocardiography of pulmonary venous flow in clinical cardiology.

Patterns of pulmonary venous and transmitral flow velocity in patients with hypertrophic cardiomyopathy

This study determines the characteristics of left atrial filling from the pulmonary veins in 80 patients with hypertrophic cardiomyopathy by transthoracic echocardiography. Patients in sinus rhythm (n = 72) showed a typical triphasic pattern with a systolic phase (J) and diastolic phase (K) and a retrograde surge of flow during atrial contraction. In sinus rhythm, three characteristic patterns of pulmonary venous flow in hypertrophic cardiomyopathy were observed: (1) an increased peak J wave relative to the K wave with J/K ratios greater than 1 (n = 43; 60%), (2) equal peak J and K phases (n = 7; 10%), and (3) decreased J wave relative to K ratios and J/K less than 1 (n = 22; 30%). The J/K ratio correlated inversely with the E/A ratio (r = -0.64; p < 0.01). In eight patients with atrial fibrillation, left atrial filling occurred primarily in diastole (K phase). Combined use of mitral and pulmonary venous flow may be optimal for the noninvasive detection of abnormal left ventricular filling in patients with hypertrophic cardiomyopathy.

Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease

Pulmonary arterial wedge pressure (PAWP) is an important marker of cardiac function. Regrettably, it requires catheterization, which can occasionally result in serious complications. A noninvasive method of estimating PAWP would thus be helpful. Recent studies have indicated that the Doppler transmitral flow velocity pattern was strongly dependent on preload and could provide an estimate of PAWP. This study was therefore designed to evaluate the relation between doppler transmitral flow velocity indexes and measured PAWP in 91 patients (learning group: 73 men, mean age 57 +/- 13 years) with ischemic heart disease (n = 41), dilated (n = 29) or hypertrophic cardiomyopathy (n = 4), or aortic stenosis (n = 17). Multiple regression analysis was used to derive an equation for estimation of PAWP, which was subsequently tested in a separate group of 33 patients (testing group: 28 men, mean age 58 +/- 12 years) with similar cardiac conditions. PAWP ranged from 4 to 48 mm Hg in the learning group and from 7 to 40 mm Hg in the testing group. In the learning group, PAWP correlated with the E/A ratio (r = 0.95), atrial filling fraction (r = -0.80), peak E velocity (r = 0.79), isovolumic relaxation period (r = -0.75), and deceleration time (r = -0.61). In the learning group, PAWP was best predicted as PAWP = 18.4 + [17.1.In(E/A ratio)]. This equation allowed prediction of PAWP within 3 mm Hg of the measured value in 24 of 33 patients (73%) in the testing group. In 8 additional patients, the equation also accurately predicted the changes in PAWP induced by volume loading or intravenous nitrates (r = 0.98).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure

OBJECTIVES

This study was designed to determine whether Doppler echocardiographic transmitral flow patterns can predict cardiac mortality in patients with congestive heart failure.

BACKGROUND

Previous studies have indicated that Doppler transmitral flow patterns are related to New York Heart Association functional class and exercise capacity in patients with congestive heart failure. However, the prognostic significance of these flow patterns is not known.

METHODS

We analyzed the relation of transmitral flow patterns and cardiac mortality in 100 consecutive patients (76 men, 24 women; mean [+/- SD] age 60 +/- 11 years) with congestive heart failure symptoms and left ventricular ejection fraction < 40%. At the time of entry into the study, functional class and ejection fraction by radionuclide angiography were determined, and Doppler echocardiography was performed in all patients. Transmitral flow was obtained from the apical four-chamber view at the mitral annulus level. Measurements included early (E) and atrial (A) filling velocities, E/A ratio and deceleration time of the E wave. The patients were assigned to two groups according to E/A ratio or deceleration time of transmitral flow patterns, or both: a non-restrictive group (42 patients) with E/A < or = 1 or E/A = 1 to 2 and deceleration time > 140 ms, and a restrictive group (58 patients) with E/A > or = 2 or E/A = 1 to 2 and deceleration time < or = 140 ms.

RESULTS

Of 100 patients, 26 died during a mean follow-up period of 16 +/- 8 months. The cumulative cardiac mortality rate determined by the Kaplan-Meier method was 14% at 1 year and 35% at 2 years. Cox proportional hazards model analysis revealed that transmitral flow (restrictive vs. nonrestrictive, chi-square 6.99, p = 0.008), patient gender (female vs. male, chi-square 4.59, p = 0.03) and New York Heart Association functional class (IV vs. II, chi-square 3.95, p = 0.05) were significantly related to cardiac mortality in patients with congestive heart failure. Mortality rate in the restrictive group was markedly higher than that in the nonrestrictive group at 1 year (19% vs. 5%, respectively, p < 0.05) and at 2 years (51% vs. 5%, respectively, p < 0.01) by log-rank test. Relative risk for cardiac death was estimated as 4.1 at 1 year and 8.6 at 2 years in the restrictive group compared with the nonrestrictive group.

CONCLUSIONS

In patients with congestive heart failure, a restrictive transmitral flow pattern, female gender and advanced functional class are predictive of higher cardiac mortality. The restrictive transmitral flow pattern by Doppler echocardiography is the single best clinical predictor for cardiac death in patients with congestive heart failure.

Detection of regional left ventricular asynchrony in obstructive hypertrophic cardiomyopathy by magnetic resonance imaging

Cine magnetic resonance imaging was used to analyze global and regional left ventricular function in seven patients with obstructive hypertrophic cardiomyopathy (HC) and 10 normal subjects. In patients with HC a 38% higher left ventricular mass index (106.4 +/- 20.2 gm/m2 vs 77.0 +/- 16.1 gm/m2, p < 0.005) associated with a lower end-diastolic volume index (44.9 +/- 8.9 ml/m2 vs 58.3 +/- 9.0 ml/m2, p < 0.005) resulted in an 85% higher mass-to-volume ratio (2.4 +/- 0.52 vs 1.3 +/- 0.57, p < 0.0005). Stroke volume did not differ significantly, whereas ejection fraction was higher (80.4% +/- 6.5% vs 65.4% +/- 7.2%, p < 0.0005) in patients with HC. Although early diastolic filling fraction was smaller in patients with HC (61.0% +/- 22.8% vs 68.4% +/- 14.6%), the difference did not reach significance because of substantial variability. In patients with HC (in contrast to normal subjects) the time to maximal wall thickening was shorter (p < 0.025) in the hypertrophied basal region of the ventricle (223 +/- 42 msec) than in the apical region (267 +/- 35 msec), reflecting asynchrony between these regions. Additionally, in patients with HC the standard deviation of the time to maximal wall thickening in the basal region was significantly higher when compared with that of normal subjects (40.0 +/- 24 msec vs 16.9 +/- 17 msec, p < 0.0005), reflecting asynchrony even within one region. Thus magnetic resonance imaging can detect regional left ventricular asynchrony, an important cause of impaired diastolic function, in patients with HC and normal global systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)