Noninvasive evaluation of pulmonary capillary wedge pressure in patients with acute myocardial infarction by deceleration time of pulmonary venous flow velocity in diastole

Contemporary usefulness of pulmonary venous flow parameters to estimate left ventricular end-diastolic pressure on transthoracic echocardiography

Measurement of pulmonary venous flow (PVF) parameters can be used to estimate left ventricular end-diastolic pressure (LVEDP) on transthoracic echocardiography. Despite that, 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) algorithm gave a secondary role to PVF to assess left ventricular filling pressure. We aimed to test correlations between several PVF parameters, including novel measurements, with LVEDP and to analyze whether PVF parameters have an incremental usefulness over ASE/EACVI algorithm to estimate LVEDP. Seventy-two patients that underwent left and right cardiac catheterization for assessment of heart failure or pulmonary hypertension were enrolled. All patients had a detailed echocardiographic study immediately before catheterization. Patients were categorized into those with an LVEDP < 15 mmHg vs. LVEDP ≥ 15 mmHg to analyze data. Patients with an elevated LVEDP had significantly lower peak S/D velocity ratio, S wave deceleration time, D wave acceleration time and D wave deceleration time (DWDT), as well as higher D wave acceleration rate (DWAR), but only peak S/D velocity ratio (β = - 0.28, p = 0.01), DWDT (β = - 0.33, p = 0.001) and DWAR (β = 0.23, p = 0.03) were independent predictors for an elevated LVEDP. ASE/EACVI algorithm had a sensitivity of 71% and specificity of 74% to predict an elevated LVEDP. When PVF parameters were adjusted for ASE/EACVI algorithm; DWDT and DWAR remained as independent predictors. Sensitivity and specificity of ASE/EACVI algorithm increased to 79% and 96%, respectively, if either DWDT or DWAR was also suggestive of an elevated LVEDP. DWDT and DWAR have incremental usefulness over existing algorithm to determine LVEDP.

Transesophageal echocardiographic evaluation of pulmonary vein diastolic wave deceleration time - As a predictor of left atrial pressure

Background:

The deceleration time of the pulmonary venous diastolic flow has been well-correlated with invasive pulmonary capillary wedge pressure in several studies regardless of left ventricular systolic function. This study was conducted to correlate deceleration time of pulmonary venous diastolic wave, DT_(D), and left atrial pressure (LAP), obtained noninvasively from mitral early diastolic inflow velocity-to-early diastolic mitral annulus velocity ratio (E/e′), and to assess the ease of each method in patients with coronary artery disease undergoing off-pump coronary artery bypass grafting (OPCAB) by transesophageal echocardiography.

Methods:

Forty-five adult patients with coronary artery disease, with left ventricular ejection fraction of ≥50% posted for elective OPCAB were enrolled in the study.

Results:

Forty values of LAP and DT_(D) were analyzed. A significant linear correlation (r = −0.64) was found between DT_(D) and LAP. Area under the curve of DT_(D) of ≤183 ms for predicting elevated LAP (>15) was 0.903 (95% confidence interval: 0.767 to 0.974, P < 0.0001).

Conclusion:

Deceleration time of pulmonary venous flow diastolic waveform, DT_(D), feasible promising echocardiographic measure in determining elevated LAP and DT_(D) ≤183 ms predicts elevated LAP.

Value of dual Doppler echocardiography for prediction of atrial fibrillation recurrence after radiofrequency catheter ablation

Background

Increasing evidence has been presented which suggests that left ventricular (LV) diastolic dysfunction may play an important role in the development of atrial fibrillation (AF). However, the potential for LV diastolic dysfunction to serve as a predictor of AF recurrence after radiofrequency catheter ablation remains unresolved.

Methods

Dual Doppler and M-PW mode echocardiography were performed in 67 patients with AF before ablation and 47 patients with sinus rhythm. The parameters measured within identical cardiac cycles included, the time interval between the onset of early transmitral flow peak velocity (E) and that of early diastolic mitral annular velocity (e’) (TE-e’), the ratio of E to color M-mode Doppler flow propagation velocity (Vp)(E/Vp), the Tei index, the ratio of E and mitral annular septal (S) peak velocity in early diastolic E/e’(S) and the ratio of E and mitral annular lateral (L) peak velocity E/e’(L). A follow-up examination was performed 1 year after ablation and patients were divided into two groups based on the presence or absence of AF recurrence. Risk estimations for AF recurrence were performed using univariate and multivariate logistic regression.

Results

TE-e’, E/Vp, the Tei index, E/e’(S) and E/e’(L) were all increased in AF patients as compared with the control group (p <  0.05). At the one-year follow-up examination, a recurrence of AF was observed in 21/67 (31.34%) patients. TE-e’ and the Tei index within the recurrence group were significantly increased as compared to the group without recurrence (p <  0.001). Results from multivariate analysis revealed that TE-e’ can provide an independent predictor for AF recurrence (p = 0.001).

Conclusions

Dual Doppler echocardiography can provide an effective and accurate technique for evaluating LV diastolic function within AF patients. The TE-e’ obtained within identical cardiac cycles can serve as an independent predictor for the recurrence of AF as determined at 1 year after ablation.

Relation Between Pulmonary Venous Flow and Left Atrial Pressure During Percutaneous Mitral Valve Repair With the MitraClip

Pulmonary venous (PV) flow may provide valuable information in terms of the severity of mitral regurgitation and left atrial (LA) pressure. We sought to find PV flow determinants of LA pressure during MitraClip procedure. We analyzed 575 PV flows in 290 patients using transesophageal echocardiography before and after MitraClip procedure. We measured peak systolic velocity (Sv), diastolic velocity (Dv), systolic velocity time integral (Svti), diastolic velocity time integral (Dvti), and those systolic to diastolic ratio as PV flow parameters. Systolic PV flow velocity was lower than diastolic PV flow velocity before the procedure, but systolic PV flow velocity markedly increased after the procedure. Peak Sv/Dv ratio and Svti/Dvti ratio after the procedure were significantly higher than those before the procedure (peak Sv/Dv; 1.06 [inter-quartile range (IQR) 0.73 to 1.34] vs 0.32 [IQR 0.03 to 0.55], p <0.001, Svti/Dvti; 1.06 [IQR 0.76 to 1.61] vs 0.26 [IQR 0.02 to 0.51], p <0.001). Peak Sv/Dv ratio and Svti/Dvti ratio were negatively correlated with mean LA pressure and LA pressure V wave, respectively (peak Sv/Dv ratio; r = -0.50 and r = -0.59, Svti/Dvti ratio; r = -0.47 and r = -0.58, p <0.001). In receiver operating characteristics curve assessing the ability of PV flow to predict mean LA pressure ≥20 mm Hg after the successful procedure, the area under the curve of peak Sv/Dv ratio was 0.76 (p <0.001). Peak Sv/Dv ratio <0.98 best predicted LA pressure ≥20 mm Hg with 77% sensitivity and 71% specificity. In conclusion, systolic PV flow velocity immediately increased in response to mitral regurgitation reduction during MitraClip procedure. PV flow velocity, specifically systolic to diastolic ratio, was useful to evaluate invasively determined LA pressure.

Challenges for 'diastology': contributions from Japanese researchers

Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)-LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA-LV-arterial coupling in patients before occurrence of overt heart failure symptoms.

Noninvasive assessment of left ventricular end-diastolic pressure with tissue Doppler imaging in patients with mitral regurgitation

BACKGROUND

The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity (E/Ea) is a widely used noninvasive tool to estimate left ventricular end diastolic pressure (LVEDP). The aim of this study was to explore whether E/Ea ratio was a reliable index for the estimation of LVEDP in patients with mitral regurgitation (MR).

METHODS

Sixteen patients with nonischemic MR (primary MR group; 6 male, 58 ± 12 years) 51 patients with ischemic MR (secondary MR group; 29 male, 63 ± 9 years) and 29 patients without MR (control group; 19 male, 53 ± 10 years) were consecutively included. The peak transmitral flow and mitral annular velocities during early diastole were measured. LVEDP was determined invasively by left heart catheterization.

RESULTS

Primary and secondary MR groups had significantly higher E/Ea ratios and LVEDP than control group. LVEDP significantly correlated with E/Ea ratio in patients with primary MR, but not in patients with secondary MR. Multiple regression analysis revealed that E/Ea ratio was an independent predictor of LVEDP in patients with primary MR. Ten patients with primary MR had LVEDP ≥15 mmHg. ROC analysis demonstrated cutoff values for E/Ea ratios as >10.5 for lateral mitral annulus (sensitivity: 80%, specificity: 66%, PPV: 80%, NPV: 66%) and as >14 for medial mitral annulus (sensitivity: 90%, specificity: 83%, PPV: 90%, NPV: 83%) to predict primary MR patients with LVEDP ≥15 mmHg.

CONCLUSION

E/Ea ratio is still reliable in estimation of LVEDP in primary MR patients while it is not predictive for LVEDP in secondary MR patients.

Left atrial longitudinal strain by speckle tracking echocardiography correlates well with left ventricular filling pressures in patients with heart failure

Background

The combination of early transmitral inflow velocity and mitral annular tissue Doppler imaging (E/Em ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However E/Em ratio has a significant gray zone and its accuracy in patients with heart failure is debated. Left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) was recently proposed as an alternative approach to estimate LV filling pressures. This study aimed at exploring the correlation of LA longitudinal function by STE and Doppler measurements with direct measurements of LV filling pressures in patients with heart failure.

Methods

A total of 36 patients with advanced systolic heart failure (ejection fraction ≤35%), undergoing right heart catheterization, were studied. Simultaneously to pulmonary capillary wedge pressure (PCWP) determination, peak atrial longitudinal strain (PALS) and mean E/Em ratio were measured in all subjects by two independent operators. PALS values were obtained by averaging all segments (global PALS), and by separately averaging segments measured in the 4-chamber and 2-chamber views.

Results

Not significant correlation was found between mean E/Em ratio and PCWP (R = 0.15). A close negative correlation between global PALS and the PCWP was found (R = -0.81, p < 0.0001). Furthermore, global PALS demonstrated the highest diagnostic accuracy (AUC of 0.93) and excellent sensitivity and specificity of 100% and 93%, respectively, to predict elevated filling pressure using a cutoff value less than 15.1%. Bland-Altman analysis confirmed this close agreement between PCWP estimated by global PALS and invasive PCWP (mean bias 0.1 ± 8.0 mmHg).

Conclusion

In a group of patients with advanced systolic heart failure, E/Em ratio correlated poorly with invasively obtained LV filling pressures. However, LA longitudinal deformation analysis by STE correlated well with PCWP, providing a better estimation of LV filling pressures in this particular clinical setting.

Pulmonary artery occlusion pressure estimation by transesophageal echocardiography: is simpler better?

The measurement of pulmonary artery occlusion pressure (PAOP) is important for estimation of left ventricular filling pressure and for distinction between cardiac and non-cardiac etiology of pulmonary edema. Clinical assessment of PAOP, which relies on physical signs of pulmonary congestion, is uncertain. Reliable PAOP measurement can be performed by pulmonary artery catheter, but it is possible also by the use of echocardiography. Several Doppler variables show acceptable correlation with PAOP and can be used for its estimation in cardiac and critically ill patients. Noninvasive PAOP estimation should probably become an integral part of transthoracic and transesophageal echocardiographic evaluation in critically ill patients. However, the limitations of both methods should be taken into consideration, and in specific patients invasive PAOP measurement is still unavoidable, if the exact value of PAOP is needed.

Echocardiographic assessment of pulmonary artery occlusion pressure in ventilated patients: a transoesophageal study

Background

Non-invasive evaluation of left ventricular filling pressure has been scarcely studied in critically ill patients. Accordingly, we prospectively assessed the ability of transoesophageal echocardiography (TEE) Doppler to predict an invasive pulmonary artery occlusion pressure (PAOP) ≤ 18 mmHg in ventilated patients.

Methods

During two consecutive 3-year periods, TEE Doppler parameters were compared to right heart catheterisation derived PAOP used as reference in 88 ventilated patients, haemodynamically stable and in sinus rhythm (age: 63 ± 14 years; simplified acute physiologic score (SAPS) II: 45 ± 12). During the initial period (protocol A), threshold values of pulsed-wave Doppler parameters to predict an invasive PAOP ≤ 18 mmHg were determined in 56 patients. Derived Doppler values were prospectively tested during the subsequent period (protocol B) in 32 patients.

Results

In protocol A, Doppler parameters had similar area under the receiver operating characteristic (ROC) curve. In protocol B, mitral E/A ≤ 1.4, pulmonary vein S/D > 0.65 and systolic fraction > 44% best predicted an invasive PAOP ≤ 18 mmHg. Lateral E/E' ≤ 8.0 or E/Vp ≤ 1.7 predicted a PAOP ≤ 18 mmHg with a sensitivity of 83% and 80%, and a specificity of 88% and 100%, respectively. Areas under ROC curves of lateral E/E' and E/Vp were similar (0.91 ± 0.07 vs 0.92 ± 0.07: p = 0.53), and not significantly different from those of pulsed-wave Doppler indices.

Conclusion

TEE accurately predicts invasive PAOP ≤ 18 mmHg in ventilated patients. This further increases its diagnostic value in patients with suspected acute lung injury/acute respiratory distress syndrome.

Restrictive physiology in cardiogenic shock: observations from echocardiography

BACKGROUND

Left ventricular diastolic abnormalities are associated with adverse outcome in myocardial infarction. Intra-aortic balloon pump (IABP) support is associated with improved diastolic filling. In the SHOCK trial and registry, average left ventricular ejection fraction (LVEF) was approximately 30%, higher than expected based on the classic paradigm. We hypothesized that restrictive physiology plays a role in cardiogenic shock (CS).

METHODS

Echocardiograms obtained during the SHOCK trial within 24 hours of randomization were centrally interpreted. Patients with quantifiable mitral E-wave deceleration time were included (n = 64). The restrictive filling pattern was defined as deceleration time < 140 milliseconds.

RESULTS

The restrictive pattern was seen in 60.9% of patients studied. Patients with this pattern had lower LVEF (31.1% vs 39.0%, P = .02) and higher wall motion score index (2.1 vs 1.8, P = .05). Patients with restriction were more likely to have IABP support during echocardiography (73.7% vs 43.5%, P = .03). There was no difference with and without restriction in demographic and hemodynamic variables or in mitral regurgitation degree or extent of coronary disease. The restrictive pattern had positive predictive value of 80% for pulmonary capillary wedge pressure > or = 20 mm Hg. Thirty-day survival was 53.9% with restriction versus 68.0% without restriction, P = .31. There was no difference in New York Heart Association class at 1 year between groups.

CONCLUSIONS

The restrictive filling pattern is common in patients with CS, which may suggest that diastolic dysfunction contributes to CS pathogenesis. Patients with the restrictive pattern had lower LVEF despite IABP support. An association between the restrictive pattern and mortality was not demonstrated; power was limited by sample size.

[Novel Doppler indexes of estimation of pulmonary capillary pressure: influence of age, feasibility in the acute setting and reproducibility]

BACKGROUND

The Doppler indexes E/Vp, E/Ea, 1000/(2 x IRT + Vp), 1000/(2 x IRT + Ea) and DTd (E: peak E mitral velocity; Vp: flow propagation velocity by color M-mode; Ea: peak early diastolic velocity at lateral mitral annulus by tissue Doppler; IRT: isovolumic relaxation time; DTd: deceleration time of the pulmonary venous diastolic wave) have been proposed for the non-invasive prediction of left ventricular filling pressures. However, the influence of age, the feasibility in acute setting and the reproducibility of these Doppler indexes have never been simultaneously investigated.

OBJECTIVE

The present study was conducted to evaluate the influence of age in 56 healthy subjects (57 +/- 20 years of age), the feasibility in 40 critically ill patients (72 +/- 13 years of age; 21 with decompensated heart failure) and the reproducibility in 15 patients.

RESULTS

Only the indexes E/Vp (R = 0.37, P = 0.005) and E/Ea (R = 0.72, P < 0.001) were correlated with age. The feasibility was 92, 90, 72, 72 and 45% for E/Ea, 1000/(2 x IRT + Ea), E/Vp, 1000/(2 x IRT +Vp) and DTd, respectively. The best reproducibility was observed for the Doppler parameters E and Ea.

CONCLUSION

Despite it is influenced by age, E/Ea appears to be the most useful index for predicting left ventricular filling pressures routinely.

Reduced coronary flow reserve in patients with congestive heart failure assessed by transthoracic Doppler echocardiography

BACKGROUND

Although coronary flow reserve (CFR) has been reported to be restricted in various conditions, there has been no report of CFR for patients with congestive heart failure (CHF). The purpose of this study was to assess coronary flow characteristics for patients with CHF.

METHODS

We studied 15 patients with CHF: 8 with dilated myocardiopathy and 7 with hypertensive heart disease. Phasic coronary flow velocities were obtained in the left anterior descending coronary artery at rest and during hyperemia (0.15 mg/kg/min adenosine triphosphate infusion intravenously) by transthoracic echocardiography before and after treatment of CHF. CFR was obtained from the ratio of hyperemic/baseline diastolic mean velocity.

RESULTS

CFR was significantly restricted in the condition of CHF compared with that after improvement of CHF (1.5 +/- 0.2 vs 2.0 +/- 0.3, P < .01). Baseline diastolic mean velocity in the condition with CHF was significantly greater than that after improvement of CHF (41 +/- 13 cm/s vs 33 +/- 13 cm/s, P = .04), although maximal hyperemic diastolic mean velocity was not significantly different before and after improvement of CHF (63 +/- 20 cm/s vs 61 +/- 19 cm/s, P = .68). After improvement of CHF, heart rate, along with left ventricular end-diastolic volume and dimension, were significantly decreased, and deceleration time of transmitral early filling flow was increased compared with before treatment of CHF. Blood pressure and ejection fraction were not significantly different before and after treatment of CHF.

CONCLUSIONS

Restriction of CFR is demonstrated during CHF because of the elevation of baseline resting flow velocity, which might be related to increase in left ventricular preload and heart rate.

Can Transthoracic Doppler Echocardiography Predict the Discrepancy Between Left Ventricular End-Diastolic Pressure and Mean Pulmonary Capillary Wedge Pressure in Patients With Heart Failure?

BACKGROUND

Left ventricular end-diastolic pressure (LVEDP) is difficult to measure continuously; therefore, pulmonary capillary wedge pressure (PCWP) is frequently used instead for hemodynamic monitoring in patients with heart failure. However, a discrepancy between LVEDP and mean PCWP is sometimes observed.

METHODS AND RESULTS

To assess the feasibility of evaluating this discrepancy using echo-Doppler indexes, 140 consecutive patients with heart disease were studied. Transthoracic Doppler echocardiography (TTDE) was performed immediately before bilateral-sided cardiac catheterization. We measured peak velocities of early (E: cm/s) and late (A: cm/s) diastolic transmitral flow, and duration of A wave (MAd: ms). We also measured the duration of atrial reversal of pulmonary venous flow (PAd: ms). The difference between PAd and MAd (Deltad = PAd-MAd: ms) was calculated. The ratio of E to tissue Doppler-derived peak early diastolic velocity of mitral annulus (Ea: cm/s) was also calculated (E/Ea). There was a good positive correlation between LVEDP and Deltad (r = 0.77, p < 0.001). There was a modest correlation between mean PCWP and E/Ea (r = 0.56, p < 0.001). When patients were classified by Deltad > or = 10 ms and E/Ea < or = 14, elevated LVEDP (> or = 17 mmHg) and normal mean PCWP (< or = 12 mmHg) were predicted with 100% sensitivity and 85% specificity.

CONCLUSIONS

Evaluation of the discrepancy between LVEDP and mean PCWP in patients with heart failure was feasible by separately estimating LVEDP by Deltad and mean PCWP by E/Ea using noninvasive TTDE. Early detection of patients with elevated LVEDP and normal mean PCWP may be useful for preventing acute exacerbation of chronic heart failure.

Noninvasive estimation of impaired hemodynamics for patients with acute myocardial infarction by Tei index

BACKGROUND

Tei index, defined as the sum of isovolumic contraction and relaxation times divided by ejection time, has been proposed to express global left ventricular function. For patients with acute myocardial infarction (AMI), left ventricular function can potentially be a major determinant of hemodynamics with limited time for compensation, such as increased brain natriuretic peptide to attenuate congestion, and usually without any intervention to modify cardiac loading on arrival at the hospital during the acute phase. We, therefore, hypothesized that left ventricular function, expressed by the Tei index, allows noninvasive estimation of impaired hemodynamics for patients with AMI.

METHODS

We studied 86 consecutive patients with first AMI (34 inferoposterior and 52 anteroseptal). Tei index was obtained as: (a - b)/b, where a is the interval between the cessation and onset of mitral flow and b is the ejection time by aortic flow by pulsed Doppler echocardiography. By using pulmonary capillary wedge pressure (PCWP) > or = 18 mm Hg or <18 mm Hg and cardiac index (CI) < or = 2.2 L/min/m(2) or > 2.2 L/min/m(2) by consecutive catheterization, patients were classified into 4 subsets: subset I with normal hemodynamics; subset II with elevated PCWP; subset III with reduced CI; and subset IV with both elevated PCWP and reduced CI.

RESULTS

For patients with inferoposterior AMI, there was no significant correlation between the Tei index and PCWP or CI. For patients with anteroseptal AMI, however, the Tei index showed significant correlation both with PCWP (r = 0.59, P <.0001) and CI (r = -0.42, P <.01). Diagnosis of impaired hemodynamics (subset II-IV) by a Tei index > or = 0.60 showed a sensitivity, specificity, and accuracy of 86%, 82%, and 83%, respectively.

CONCLUSIONS

Although the Tei index has limitations to evaluate hemodynamics in patients with inferoposterior AMI, the index allows approximate but quick and practical noninvasive estimation of impaired hemodynamics in patients with anteroseptal AMI.

Value of tissue Doppler imaging to predict left ventricular filling pressure in patients with coronary artery disease

Assessment of left ventricular (LV) diastolic filling pressure provides important information on the hemodynamic status in the general population. The aim of our study was to investigate the reliability of tissue Doppler imaging (TDI) in estimating left ventricular filling pressure in patients with coronary artery disease (CAD). We prospectively studied 32 consecutive CAD-patients, mean age 64 +/- 12 years, in sinus rhythm. All patients underwent cardiac catheterization and echocardiography within the same hour. Catheterization investigated pre-A-wave pressure (preA) and LV ejection fraction (LVEF). Echocardiographic LVEF was calculated using wall motion indexes (WMI) with segmental division of LV wall. The following Doppler parameters were assessed: (1) PW Doppler signals from the mitral inflow (E), (2) PW TDI of the mitral annulus (E'), thus allowing to obtain the mitral inflow to annulus ratio (E/E'). The best correlation between invasive and echocardiographic LVEF was observed using WMI (r = 0.91). The correlations between preA and E, E', and E/E' were significant (r = 0.36, r = 0.38, and r = 0.60, respectively). In patients with LVEF >50%, no correlation between E/E' and preA was found (r = 0.18, P = 0.44), whereas with LVEF <50%, this correlation was strong (r = 0.76, P < 0.001). In patients with myocardial infarction, the correlation between E/E' and preA was significant whatever the localization of myocardial infarction (r > 0.71, P < 0.05). ROC curve analysis identified an E/E'>9 to be the best cut-off value related to preA > 15 mmHg. We conclude that the mitral inflow-to-annulus ratio is a reliable method in CAD patients and allows determination of LV filling pressure when LVEF <50%.

Noninvasive differentiation of pseudonormal/restrictive from normal mitral flow by Tei index: a simultaneous echocardiography-catheterization study in patients with acute anteroseptal myocardial infarction

BACKGROUND

Differentiation of pseudonormal/restrictive from normal mitral flow is still clinically problematic. Pseudonormal/restrictive flow is usually associated with left ventricular dysfunction, which can be detected by Doppler Tei index, combining systolic and diastolic function. Therefore, the purpose of this study was to test the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow.

METHODS

In 26 patients with anteroseptal acute myocardial infarction and early diastolic mitral flow velocity (E) to late diastolic mitral flow velocity (A) ratio (E/A) > or = 1, left ventricular volumes; E and A; deceleration time of E; and the Tei index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated by Doppler echocardiography, and pulmonary capillary wedge pressure was measured by catheterization. Pseudonormal/restrictive mitral flow was defined as E/A > or = 1 associated with pulmonary capillary wedge pressure > 12 mm Hg.

RESULTS

There were 19 and 7 patients with pseudonormal/restrictive and normal mitral flow, respectively. Among the indices of left ventricular function, the Tei index achieved the best correlation with pulmonary capillary wedge pressure (r(2) = 0.66, P <.0001). By setting the Tei index > or = 0.55 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had the sensitivity, specificity, and accuracy of 84%, 100%, and 88%, respectively.

CONCLUSION

The Tei index allows noninvasive differentiation of pseudonormal/restrictive from normal mitral flow.

Prognostic value of pseudonormal and restrictive filling patterns on left ventricular remodeling and cardiac events after coronary artery bypass grafting

This study was aimed to assess the prognostic value of transmitral flow (TMF) patterns on patients after coronary artery bypass grafting (CABG). TMF, left ventricular (LV) end-diastolic diameter (LVDd) and LV ejection fraction (LVEF) were studied in 102 patients before and after CABG by echocardiography. Patients were subdivided into 4 groups according to TMF patterns during hospital stay shortly after CABG; group 1 (n = 37) had normal filling patterns; group 2 (n = 29) had abnormal relaxation patterns; group 3 (n = 24) had pseudonormal patterns; and group 4 (n = 12) had restrictive patterns. One year after CABG, LVDd was greater and LVEF was lower in groups 3 and 4 than in groups 1 and 2, although there were no significant differences in LVDd and LVEF among the 4 groups before and shortly after CABG. During the follow-up period of 29 +/- 20 months, 19 patients had cardiac events. The incidence of cardiac events in groups 3 and 4 determined by the Kaplan-Meier method was significantly higher than that in groups 1 and 2 (Mantel-Cox test, p <0.01). Patients' gender, clinical findings, and echocardiographic variables were compared for their ability to predict cardiac events by means of the Cox proportional hazards model, and only the LVDd and TMF patterns during the hospital stay after CABG were recognized as independent predictors of cardiac events (chi-square 4.9 and 11.3, respectively; p <0.05). Pseudonormal or restrictive TMF patterns during hospital stay shortly after CABG are useful indicators for predicting outcome.

Myocardial performance index (Tei index) does not reflect long-term changes in left ventricular function after acute myocardial infarction

AIMS

To evaluate whether changes in myocardial performance index (MPI or Tei index) were related to changes in other Doppler echocardiographic parameters after acute myocardial infarction, or had any independent prognostic impact in a 2-year observational study.

METHODS AND RESULTS

Seventy-one patients with acute myocardial infarction without heart failure were examined at baseline, 3 months, and 2 years. MPI was significantly related to end-diastolic and end-systolic volume indexes, ejection fraction, maximal velocity, and time velocity integral of early mitral filling wave at 3 months and 2 years. MPI did not contribute significantly to the prediction of any changes in the measures of diastolic or systolic function at 3 months or 2 years. Baseline MPI was significantly higher in patients who later developed heart failure(0.55 +/- 0.16)than in other patients(0.43 +/- 0.13, P = 0.006), but had no independent predictive power for the development of heart failure or death relative to end-systolic volume index and deceleration time of early mitral filling wave.

CONCLUSION

MPI did not accurately reflect changes in Doppler and two-dimensional echocardiographic measures of diastolic or systolic function during a 2-year follow-up after acute myocardial infarction, and did not have any independent prognostic impact.

Comparison of Doppler echocardiography, color M-mode Doppler, and Doppler tissue imaging for the estimation of pulmonary capillary wedge pressure

To overcome the limitations of mitral inflow parameters for predicting pulmonary capillary wedge pressure (PCWP), combined indices (with Doppler tissue imaging or color M-mode Doppler) have been developed. This study was aimed to compare the accuracy of these indices to predict PCWP. Sixty-one patients were studied. The best correlations with PCWP were found for indices that combined isovolumic relaxation time with flow propagation velocity (color M-mode) or early diastolic velocity of the lateral mitral annulus (Doppler tissue). Both closely tracked changes in PCWP. The color M-mode-derived index was the most accurate in patients with normal systolic function.

Noninvasive differentiation of normal from pseudonormal/restrictive mitral flow using TEI index combining systolic and diastolic function

Differentiation of normal from pseudonorma/restrictive mitral flow is not necessarily easy. Pseudonormal/restrictive flow is usually associated with left ventricular (LV) dysfunction, which can be detected using the TEI index, combining systolic and diastolic function. The purpose of this study was to test the feasibility of using the TEI index to differentiate pseudonormal/restrictive from normal mitral flow. In 33 patients with mitral flow E/A > or = 1 and LV mid-diastolic pressure measured by catheterization, the LV volumes, mitral E and A velocity, deceleration time of the E velocity, and the TEI index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated using Doppler echocardiography. Pseudonormal/restrictive mitral flow was defined as mitral flow E/A > or = 1 associated with LV mid-diastolic pressure > 12 mmHg. There were 22 and 11 patients with normal and pseudonorma/restrictive mitral flow, respectively. Among the indices of LV function, the TEI index achieved the best correlation with LV mid-diastolic pressures (r2 = 0.63, p < 0.0001). By setting the TEI index > or = 0.65 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had sensitivity, specificity, and accuracy of 82%, 96%, and 91%, respectively. TEI index allows noninvasive differentiation of pseudonormal /restrictive from normal mitral flow.

Comparison of transthoracic Doppler echocardiography and natriuretic peptides in predicting mean pulmonary capillary wedge pressure in patients with chronic atrial fibrillation

The purpose of this study was to assess whether transthoracic Doppler echocardiography and serum natriuretic peptide levels could predict mean pulmonary capillary wedge pressure (PCWP) in patients with chronic atrial fibrillation. We examined mitral flow velocity and pulmonary venous flow (PVF) velocity patterns in 32 patients with chronic atrial fibrillation. Plasma A-type and B-type natriuretic peptide (ANP, BNP, respectively) levels in the peripheral vein were measured. Significant correlations were observed between mean PCWP and the following: peak velocity (r = 0.51) and deceleration time (r = -0.65) of the mitral flow; peak velocity (r = 0.64) and deceleration time (r = -0.80) of the PVF; BNP (r = 0.60); and ANP (r = 0.36). Stepwise multiple linear regression analysis selected PVF deceleration time and mitral flow deceleration time as independent predictors of PCWP. A cutoff value of PVF deceleration time of < or =150 ms and a mitral flow deceleration time of < or =100 ms predicted a mean PCWP of > or =18 mm Hg, with a sensitivity of 100% and 80% and a specificity of 96% and 85%, respectively. In conclusion, PVF deceleration time and mitral flow deceleration time obtained from transthoracic Doppler echocardiography are more accurate predictors of mean PCWP than values obtained with natriuretic peptides in patients with chronic atrial fibrillation.

The deceleration [correction of declaration] time of pulmonary venous diastolic flow is more accurate than the pulmonary artery occlusion pressure in predicting left atrial pressure

OBJECTIVES

This study compared a prediction of mean left atrial pressure (P(LA)) ascertained by Doppler echocardiography of pulmonary venous flow (PVF), with predicted P(LA) using the pulmonary artery occlusion pressure (P(PAO)).

BACKGROUND

In select patient groups, PVF variables correlate with P(PAO)) an indirect measure of P(LA).

METHODS

In 93 patients undergoing cardiac surgery, we recorded with transesophageal echocardiography mitral valve early (E) and late (A) wave velocities, deceleration time (DT) of E (DT(E)), and pulmonary vein systolic (S) and diastolic (D) wave velocities, DT of D (DT(D)) and systolic fraction. The P(PAO) was measured using a pulmonary artery catheter zeroed to midaxillary level. A further catheter was held at midatrial level to zero a transducer and was then inserted into the left atrium. A prediction rule for P(LA) from DT(D) was developed in 50 patients and applied prospectively to estimate P(LA) in 43 patients.

RESULTS

A close correlation (r = -0.92) was found between P(LA) and DT(D). Systolic fraction (r = -0.63), DT(E) (r = -0.61), D wave (r = 0.57), E wave (r = 0.52), and E/A ratio (r = 0.13) correlated less closely with P(LA). The mean difference between predicted and measured P(LA) was 0.58 mm Hg for DT(D) method and 1.72 mm Hg for P(PAO), with limits of agreement (mean +/- 2 SE) of -2.94 to 4.10 mm Hg and -2.48 to 5.92 mm Hg, respectively. A DT(D)) of <175 ms had 100% sensitivity and 94% specificity for a P(LA) of >17 mm Hg.

CONCLUSIONS

Deceleration time of pulmonary vein diastolic wave is more accurate than P(PAO) in estimating left atrial pressure in cardiac surgical patients.