Short deceleration time of mitral inflow E velocity: prognostic implication with atrial fibrillation versus sinus rhythm

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

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

Echocardiographic Evaluation of Diastolic Function in Special Populations

Left ventricular (LV) diastolic dysfunction results from a combination of impaired relaxation, reduced restoring forces, and increased chamber stiffness. Noninvasive assessment of diastology uses a multiparametric approach involving surrogate markers of increased filling pressures, which include mitral inflow, septal and lateral annular velocities, tricuspid regurgitation velocity, and left atrial volume index. However, these parameters must be used cautiously. This is because the traditional algorithms for evaluating diastolic function and estimation of LV filling pressures (LVFPs), as recommended by the American Society of Echocardiography and European Association of Cardiovascular Imaging 2016 guidelines, do not apply to unique patients with underlying cardiomyopathies, significant valvular disease, conduction abnormalities, arrhythmias, LV assist devices, and heart transplants, which alter the relation between the conventional indexes of diastolic function and LVFP. The purpose of this review is to provide solutions for evaluating LVFP through illustrative examples of these special populations, incorporating supplemental Doppler indexes, such as isovolumic relaxation time, mitral deceleration time, and pulmonary venous flow analysis, as needed to formulate a more comprehensive approach.

Correlation between catecholamines and echocardiographic parameters in patients with pheochromocytoma and paraganglioma

PURPOSE

To analyze the correlation between catecholamines and echocardiographic parameters in patients with pheochromocytoma and paraganglioma (PPGL).

METHODS

Sixty-six patients who underwent surgical resection of pathologically proven PPGL from January 2016 to June 2019 were examined. Echocardiographic parameters were compared between patients with elevated catecholamine concentrations and those with normal concentrations.

RESULTS

The percentage of patients with elevation of any catecholamine (NE, DA, or E, and their metabolites) did not significantly differ between patients with normal and abnormal left ventricular ejection function (LVEF) or diastolic function (LVDF). E wave deceleration time (EDT) was significantly lower in patients with elevation of any catecholamine than in those with normal concentrations (p = 0.024). EDT was significantly lower in patients with elevated NE and its metabolites than in patients with normal NE concentration (p = 0.004). After adjusting for gender and age, EDT was significantly negatively correlated with elevated NE and its metabolites in regression analysis (B-value, -39.853; p = 0.023) and correlation analysis (r = -0.349; p = 0.004).

CONCLUSION

NE and its metabolites may have an impact on left ventricular diastolic function, which can be reflected by EDT. EDT was negatively correlated with elevated NE and its metabolites.

Predictive power of diastolic parameters on medical cardioversion success in acute atrial fibrillation

BACKGROUND

Diastolic function assessment has been reported to provide valuable data in patients with atrial fibrillation (AF). The purpose of this study was to evaluate the effects of diastolic parameters on predicting the effectiveness of medical cardioversion in restoring sinus rhythm among patients with acute AF.

METHODS

40 non-valvular, new onset AF patients were included. All participants received an intravenous infusion of amiodarone. In patients whom sinus rhythm could not be restored with amiodarone, an electrical cardioversion was performed. Two groups, patients who achieved sinus rhythm with amiodarone (Group-1) and who failed to achieve sinus rhythm with amiodarone (Group-2) were compared with respect to initial echocardiographic measurements.

RESULTS

Group-1 patients were younger comparing with Group-2 (mean age; 54.4 ± 13.9 years vs 63.3 ± 10.3 years, p = 0.028). Comparing with Group-1, Group-2 patients had; a higher left atrium volume index (17.1 ± 4.8 cm³ / m² vs 22.6 ± 6.6 cm³ / m² , p = 0.03); a shorter pulmonary vein S (49.6 ± 3.8 cm/sec vs 41.1 ± 3.0 cm/sec, p < 0.001); and a shorter pulmonary vein D peak velocity (55.9 ± 2.4 cm/sec vs 52.3 ± 1.8 cm/sec, p < 0.001). Moreover, both IVRT and DT were significantly shorter in Group-2, comparing with Group-1 (45.1 ± 2.1 msec vs 51.1 ± 2.5 msec, p < 0.001 and 51.3 ± 2.4 msec vs 56.5± 3.2 msec, p < 0.001, respectively).

CONCLUSION

The present study revealed that admission pulmonary vein S and D wave peak velocities, IVRT, DT, and Pro-BNP levels could be predictors of failure of medical cardioversion among AF patients.

Prevalence of left ventricular diastolic dysfunction by cardiac magnetic resonance imaging in thalassemia major patients with normal left ventricular systolic function

Background

The leading cause of mortality of thalassemia major patients is iron overload cardiomyopathy. Early diagnosis with searching for left ventricular diastolic dysfunction before the systolic dysfunction ensued might yield better prognosis. This study aimed to define the prevalence of the left ventricular diastolic dysfunction (LVDD) in thalassemia major patients with normal left ventricular systolic function and the associated factors.

Methods

Adult thalassemia major patients with normal left ventricular systolic function who were referred for cardiac T2* at Siriraj Hospital – Thailand’s largest national tertiary referral center – during the October 2014 to January 2017 study period. Left ventricular diastolic function was defined by mitral valve filling parameters and left atrial volume index using CMR. Patients with moderate to severe valvular heart disease, pericardial disease, or incomplete data were excluded. Baseline characteristics, comorbid diseases, current medication, and laboratory results were recorded and analyzed.

Results

One hundred and sixteen patients were included, with a mean age of 27.5 ± 13.5 years, 57.8% were female, and 87.9% were transfusion dependent. Proportions of homozygous beta-thalassemia and beta-thalassemia hemoglobin E were 12.1 and 87.9%, respectively. The baseline hematocrit was 26.3 ± 3.3%. The prevalence of LVDD was 20.7% (95% CI: 13.7–29.2%). Cardiac T2* was abnormal in 7.8% (95% CI: 3.6–14.2%). Multivariate analysis revealed age, body surface area, homozygous beta-thalassemia, splenectomy, heart rate, and diastolic blood pressure to be significantly associated with LVDD.

Conclusions

LVDD already exists from the early stages of the disease before the abnormal heart T2 * is detected. Homozygous beta-thalassemia and splenectomy were strong predictors of LVDD. These data may increase awareness of the disease, especially in the high risk groups.

Refractory Hypotension after Cardioversion in a Patient with Atrial Fibrillation and Congestive Heart Failure

A 63-year-old woman with atrial fibrillation visited our hospital due to decompensated heart failure. Because atrial fibrillation was considered a remarkable precipitating factor for heart failure, cardioversion was performed. After cardioversion, refractory hypotension and cardiopulmonary arrest occurred. An arterial blood gas analysis showed marked lactic acidosis. Chronic kidney disease, heart failure, sedatives, and hypoventilation might have contributed to refractory hypotension due to severe acidosis in this case.

Unusual Case of Cardiac Amyloidosis Preceded by a Twenty-year History of Dilated Cardiomyopathy and Heart Failure

Amyloidosis is a well-known but uncommon disease, and the physician must maintain a high index of suspicion in order to make a timely diagnosis. The expected survival of patients with cardiac amyloidosis is generally poor. In particular, survival has been reported to be 4-12 months for patients with amyloid light-chain amyloidosis with congestive heart failure. We herein report a rare case of cardiac amyloidosis in which the patient presented with cardiac hypertrophy after a 20-year history of dilated cardiomyopathy and heart failure.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Role of echocardiography in the contemporary management of chronic heart failure

Echocardiography is an excellent noninvasive tool for the assessment of ventricular size and both systolic and diastolic function, and it is routinely used in patients with heart failure. This review will discuss the role of echocardiography in heart failure diagnosis, prognostic assessment and in the management of heart failure patients.

Perioperative Diastolic Dysfunction

Left ventricular diastolic dysfunction (LVDD) has only recently been recognized as an important determinant of perioperative morbidity. Intraoperative echocardiographers have been slow to adopt assessment of LVDD into clinical practice. This has been partly attributable to the complex measurements required to characterize LVDD, which are in turn related to how our understanding of diastole has evolved. Additionally, the lack of effective therapeutic options has left many wondering whether it is worthwhile to characterize this pathology in the first place. However, therapies are developed more rapidly once a problem can be identified reliably. The assessment of LVDD is centered on how effectively the left ventricle can fill. Diastolic dysfunction affects intraventricular pressures and stiffness, which in turn affect the pressure relationship between the left atrium and the left ventricle thereby affecting transmitral flow. Since echocardiography can enable the measurement of flow velocities, transmitral diastolic filling flow patterns provide robust information on diastolic function. The impact of abnormal diastolic function on left atrial pressure has consequences for pulmonary venous flow, which can also be measured with echocardiography. However, given the limitations of flow velocity, direct measurement of tissue velocity can significantly improve the characterization of diastolic dysfunction. The evolution of Doppler and speckle-based methods of assessing tissue motion have vastly improved our understanding of diastolic function. With the development of simpler algorithms for categorization, and their gradual adoption by perioperative echocardiographers, LVDD should be better diagnosed and treated to improve postoperative outcomes.

Left ventricular diastolic function and long-term outcomes in patients with normal exercise echocardiographic findings

The objective of the present study was to determine whether diastolic dysfunction (DD) is associated with outcomes in the absence of myocardial ischemia. We studied 2,835 patients undergoing exercise echocardiography from January 2006 through December 2006 who had normal systolic function (ejection fraction ≥50%) and an absence of exercise-induced wall motion abnormalities. Diastolic function was graded as normal, mild DD, or moderate to severe DD. Medical records review and patient contact were undertaken to determine mortality, cardiovascular events (i.e., death, myocardial infarction, or stroke), incident heart failure (HF), and hospitalization. The mean ± SD age was 58.9 ± 12.8 years, and 54.0% were women. DD was present in 40.0% of the participants, with mild DD in 28.2% and moderate to severe DD in 11.8%. During a median follow-up of 4.4 years, 81 deaths and 114 cardiovascular events occurred, and DD was associated with greater rates of mortality, cardiovascular events, and HF events or hospitalizations (all p <0.001). On multivariate analysis, mild or moderate to severe DD (referent, normal function) was associated with HF or hospitalization (hazard ratio 1.45, 95% confidence interval 1.18 to 1.78, p <0.001 for mild DD; hazard ratio 1.75, 95% confidence interval 1.37 to 2.24, p <0.001 for moderate to severe DD) but was not independently associated with death or cardiovascular events. The diastolic index of filling pressure (E/e') was independently associated with mortality, cardiovascular events, and HF or hospitalization. In conclusion, among patients without demonstrable myocardial ischemia, left ventricular DD was associated with greater event rates during long-term follow up but did not independently predict hard end points other than HF or hospitalization. E/e' was independently associated with the clinical outcomes and might be an important echocardiographically derived parameter to identify in patients undergoing exercise echocardiography.

Impact of body mass index on diastolic function in patients with normal left ventricular ejection fraction

Background:

Obesity is a major public health epidemic and is associated with increased risk of heart failure and mortality. We evaluated the impact of body mass index (BMI) on the prevalence of diastolic dysfunction (DD).

Methods:

We reviewed clinical records and echocardiogram of patients with baseline echocardiogram between 1996 and 2005 that showed normal left ventricular ejection fraction (LVEF). Diastolic function was labeled as normal, stage 1, stage 2 or stage 3/4 dysfunction. Patients were categorized as normal weight (BMI <25 kg m⁻²), overweight (25–29.9 kg m⁻²), obese (30–39.9 kg m⁻²) and morbidly obese (⩾40 kg m⁻²). Multivariable ordinal and ordinary logistic regression were performed to identify factors associated with DD, and evaluate the independent relationship of BMI with DD.

Results:

The cohort included 21 666 patients (mean (s.d.) age, 57.1 (15.1); 55.5% female). There were 7352 (33.9%) overweight, 5995 (27.6%) obese and 1616 (7.4%) morbidly obese patients. Abnormal diastolic function was present in 13 414 (61.9%) patients, with stage 1 being the most common. As BMI increased, the prevalence of normal diastolic function decreased (P<0.0001). Furthermore, there were 1733 patients with age <35 years; 460 (26.5%) and 407 (23.5%) were overweight and obese, respectively, and had higher prevalence of DD (P<0.001). Using multivariable logistic regression, BMI remained significant in both ordinal (all stages of diastolic function) and binary (normal versus abnormal). Also, obesity was associated with increased odds of DD in all patients and those aged <35 years.

Conclusions:

In patients with normal LVEF, higher BMI was independently associated with worsening DD.

The prognostic importance of a history of hypertension in patients with symptomatic heart failure is substantially worsened by a short mitral inflow deceleration time

BACKGROUND

Hypertension is a common comorbidity in patients with heart failure and may contribute to development and course of disease, but the importance of a history of hypertension in patients with prevalent heart failure remains uncertain.

METHODS

3078 consecutively hospitalized heart failure patients (NYHA classes II-IV) were screened for the EchoCardiography and Heart Outcome Study (ECHOS). The left ventricular ejection fraction (LVEF) was estimated by 2 dimensional transthoracic echocardiography in all patients and a subgroup of 878 patients had additional data on pulsed wave Doppler assessment of transmitral flow available. A restrictive filling (RF) was defined as a mitral inflow deceleration time ≤140 ms. Patients were followed for a median of 6.8 (Inter Quartile Range 6.6-7.0) years and multivariable Cox regression models were used to assess the risk of all-cause mortality associated with hypertension.

RESULTS

The study population had a mean age of 73 ± 11 years. 39% were female, 27% had a history of hypertension and 48% had a RF. Over the study period, 64% of the population died. Hypertension was not associated with increased risk of mortality, hazard ratio (HR) 0.95 (0.85-1.05). LVEF did not modify this relationship (p for interaction = 0.7), but RF pattern substantially influenced the outcomes associated with hypertension (p for interaction < 0.001); HR 0.75 (0.57-0.99) and 1.41 (1.08-1.84) in patients without and with RF, respectively.

CONCLUSIONS

In patients with symptomatic heart failure, a history of hypertension is associated with a substantially increased relative risk of mortality among patients with a restrictive transmitral filling pattern.

Prognostic importance of a restrictive transmitral filling pattern in patients with symptomatic congestive heart failure and atrial fibrillation

BACKGROUND

Restrictive diastolic filling pattern is associated with increased mortality in patients with myocardial infarction and heart failure. Most studies have excluded patients with atrial fibrillation. The aim of the present study was to assess the prognostic value of a restrictive filling pattern in patients with atrial fibrillation.

METHODS

Doppler echocardiography including pulsed wave Doppler assessment of transmitral flow was performed in 880 patients with a clinical diagnosis of heart failure on hospital admission. Filling was considered restrictive when the mitral deceleration time <or=140 milliseconds.

RESULTS

On admission, 337 (39%) of the patients had atrial fibrillation. Among patients in atrial fibrillation, 170 (50%) had a restrictive filling; and in patients in sinus rhythm, 256 (47%) had restrictive filling (P = .34). During follow-up of median 6.7 years (range 5.3-7.8), 564 patients died (64%). Mortality was significantly higher in patients with a restrictive filling pattern irrespective of atrial fibrillation or sinus rhythm (P < .001). In a multivariable model only including patients in atrial fibrillation, a restrictive filling pattern remained a significant predictor of all-cause mortality (hazard ratio 1.79, 95% CI 1.24-2.58, P =.002).

CONCLUSIONS

In a heterogeneous population hospitalized for symptomatic heart failure, a restrictive transmitral filling pattern during hospitalization is an ominous prognostic sign also in patients presenting with atrial fibrillation.

Prognostic value of short-deceleration time of mitral inflow E velocity: implications in patients with atrial fibrillation and left-ventricular systolic dysfunction

OBJECTIVE

The aim of this prospective study was to evaluate the contribution of an initially shortened deceleration time of mitral inflow E velocity (E-wave DT) to predict survival in patients with left-ventricular (LV) systolic dysfunction in atrial fibrillation (AF) and in sinus rhythm (SR).

BACKGROUND

To date, few data are available concerning the prognostic value of Doppler mitral profile in patients with AF, particularly in the presence of LV systolic dysfunction.

METHODS

We studied the outcome of 140 consecutive patients with LV ejection fraction less than 40%. Complete history, physical examination and echocardiography were performed.

RESULTS

Chronic AF was present in 40 (29%) patients. Over a mean follow-up of 25+/-11 months, 54 (39%) patients died, 18 in the AF group and 36 in the SR group. Ejection fraction was similar in the two groups (31% versus 32%, respectively). Survival curves indicated a significantly poorer prognosis for shortened E-wave DT less than 150 ms in the AF group and in the SR group (both p<or=0.01). Using multivariable Cox analysis, shortened E-wave DT was identified as an independent predictor of mortality in the AF group (exponential of coefficient: 0.97; chi-square: 5.82; p=0.01) and in the SR group (exponential of coefficient: 0.98; chi-square: 5.82; p=0.001).

CONCLUSION

In patients with LV systolic dysfunction, a shortened deceleration time E-wave on Doppler examination appears to predict a similar poor prognosis in patients with AF as with SR.

Echocardiographic assessment of left ventricular diastolic function and filling pressure in atrial fibrillation

Diastolic dysfunction has been linked to 2 epidemics: atrial fibrillation (AF) and heart failure. The presence and severity of diastolic dysfunction are associated with an increased risk for first AF and first heart failure in patients with sinus rhythm. Furthermore, the risk for heart failure is markedly increased once AF develops. The evaluation of diastolic function once AF has developed remains a clinical challenge. The conventional use of Doppler echocardiography for the assessment and grading of diastolic dysfunction relies heavily on evaluating the relation of ventricular and atrial flow characteristics. The mechanical impairment of the left atrium and the variable cycle lengths in AF render the evaluation of diastolic function difficult. A few Doppler echocardiographic methods have been proved clinically useful for the estimation of diastolic left ventricular filling pressures in AF, but these appear to be underutilized. Several innovative methods are emerging that promise to provide greater precision in diastolic function assessment, but their clinical utility in AF remains to be established. In conclusion, this review provides an up-to-date discussion of the evaluation of diastolic function assessment in AF and how it may be important in the clinical management of patients with AF.

A simple Doppler echocardiography method to evaluate pulmonary capillary wedge pressure in patients with atrial fibrillation

OBJECTIVE

The accuracy of E/E' ratio has not been validated in atrial fibrillation (AF). The objective of this study is to compare the accuracy of the E/E' ratio averaged over a sample of 10 cardiac cycles and E/E' ratio obtained in the cycle with the longest RR interval for the estimation of wedge pressure in patients with AF using a simultaneous pulmonary artery occlusive pressure measured with a Swan-Ganz catheter.

DESIGN

Twenty-four consecutive patients with AF with a Swan-Ganz catheter were recruited in this study. The majority of patients (92%) were in the early postoperative phase of cardiac surgery.

RESULTS

The best sensitivity and specificity was reached with E/E' ratio in the medial position using the one-beat method; E/E' ratio > or = 16 with one beat predicts a wedge pressure >15 mmHg with a sensitivity and specificity of 91% and 85%, respectively.

CONCLUSIONS

Measuring E/E' ratio using the one-beat method is a simple and clinically accurate way to estimate wedge pressure in patients with AF.

Role of Echocardiography in the Diagnostic Assessment and Etiology of Heart Failure in the Elderly—Opacify, Quantify, and Rectify

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance; estimate the cardiac output, pulmonary artery, and ventricular filling pressures; and identify surgically correctable valve disease. Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pacemaker leads.

Arginine 16 Glycine β2-Adrenoceptor Polymorphism and Cardiovascular Structure and Function in Patients with Heart Failure

The beta2/beta1 adrenoceptor ratio increases in congestive heart failure (CHF), making the heart relatively more dependent on inotropic, lusitropic, and chronotropic stimulation by the beta2-adrenergic receptor (ADRB2). In healthy human beings, those who are homozygous for arginine (Arg) at amino acid 16 of the ADRB2 have reduced receptor function when compared with individuals homozygous for glycine (Gly) at this position. The cardiovascular effects of the Arg16Gly polymorphism of the ADRB2 in CHF are not well understood. The aim of this study was to examine the influence of common polymorphisms of the ADRB2 on cardiovascular structure and function in patients with CHF. Echocardiography, neurohormonal assays, and exercise tests were performed in 68 healthy individuals and 95 patients with CHF. All of the patients with CHF were stable, New York Heart Association class II to III, of ischemic or nonischemic cause, with an ejection fraction of 40% or less. Of the patients with CHF, 16 were Arg/Arg, 36 were Arg/Gly, and 43 were Gly/Gly at amino acid 16. In those without CHF, the Arg16Gly polymorphism of the ADRB2 had no effect on cardiovascular function. In contrast, in CHF, Arg/Arg homozygotes had higher plasma norepinephrine and atrial natriuretic peptide levels, greater left atrial diastolic dimension, higher peak velocity of early/late diastolic filling ratio, and shorter deceleration time compared with Gly16 homozygotes. Furthermore, Arg16 homozygotes had reduced exercise tolerance compared with Gly16 homozygotes (evidenced by shorter exercise duration and lower peak oxygen consumption per unit time), and a lesser chronotropic response to exercise. In patients with CHF, but not in demographically matched healthy persons, the Arg16Gly polymorphism of the ADRB2 exerts important effects on cardiovascular structure and function, neurohormonal activation, and exercise tolerance.

Characterization of Outpatients With Isolated Diastolic Dysfunction and Evaluation of the Burden in a Japanese Community Sado Heart Failure Study

BACKGROUND

The incidence of diastolic heart failure (DHF) is increasing with the aging of the community and identifying patients with isolated diastolic dysfunction (IDD) is important for preventing DHF. However, very little information is available about such patients in the Japanese community.

METHODS AND RESULTS

The medical information of all outpatients with moderate to severe IDD was extracted from the records of approximately 6,948 individuals who underwent echocardiographic (Echo) examinations during the past 5 years in Sado Island. Of the 284 patients extracted, 272 survived until 2003. In January 2003 the proportion of patients with moderate to severe IDD in the general population sector aged 45-84 years was 0.9% for males and 0.5% for females, and this proportion increased sharply after the age of 65 in both genders, reaching 1.6% for men in their 70 s and 0.8% for women in their 80 s. On Echo, 165 patients (61%) showed hypertrophic left ventricular geometry. The Charlson comorbidity index score was < or = 1 in 63% of patients. The cumulative survival of IDD patients, irrespective of a history of congestive heart failure (HF), was significantly lower than in the general population.

CONCLUSIONS

Moderate to severe IDD is not uncommon in the elderly and has a poor prognosis. Characteristics of outpatients with IDD should be taken into consideration when establishing a preventive strategy for HF in the Japanese community.

Role of echocardiography in the diagnostic assessment and etiology of heart failure in the elderly--opacify, quantify, and rectify

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance;estimate the cardiac output, pulmonary artery, and ventricular fill-ing pressures; and identify surgically correctable valve disease.Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pace-maker leads.

Echocardiography in atrial fibrillation

Atrial fibrillation is the most commonly encountered sustained arrhythmia. Echocardiography has augmented the knowledge about etiology and complications of atrial fibrillation. Transthoracic echocardiography allows rapid, safe and comprehensive assessment of cardiac structure and function, and is recommended for all subjects with atrial fibrillation. The use of transesophageal echocardiography has contributed to a better understanding of the thromboembolic risk in patients with atrial fibrillation, especially in the setting of electrical cardioversion. Several investigators have demonstrated the feasibility and safety profile of early cardioversion with short-term anticoagulation in patients with atrial fibrillation and a transesophageal echocardiography negative for atrial thrombi. More recently, transesophageal and intracardiac echocardiography have been employed in patients with atrial fibrillation to monitor percutaneous procedures such as pulmonary veins radiofrequency ablation or left atrial appendage obliteration. In this review the available echocardiographic imaging modalities and their specific role in the evaluation and management in atrial fibrillation are described.

Tissue Doppler-derived index of left ventricular filling pressure, E/E', predicts survival of patients with non-valvular atrial fibrillation

OBJECTIVES

To investigate whether the ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (E') predict prognosis in patients with non-valvular atrial fibrillation.

METHODS

230 patients with non-valvular atrial fibrillation were enrolled and studied. According to E/E' value, patients were divided into groups with lower (group A with E/E' <or= 15) and higher (group B with E/E' > 15) E/E'.

RESULTS

During follow up (average 245 days), 21 (9.1%) deaths were documented. All cause death (15/90 (16.7%) v 6/140 (4.3%)), cardiac death (10 (11.1%) v 2 (1.4%)) and congestive heart failure (16 (17.8%) v 8 (5.7%)) were more common in group B than in group A (all p < 0.01). A Kaplan-Meier survival curve showed that the cumulative survival rate was significantly lower in group B than in group A (log rank p = 0.0013). By multivariate logistic regression analysis, E/E' (chi(2) = 4.47, odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01 to 1.11, p = 0.03) and age (chi(2) = 6.45, OR 1.06, 95% CI 1.01 to 1.11, p = 0.02) were independent predictors of mortality.

CONCLUSION

The Doppler-derived index of left ventricular filling pressure, E/E', is a powerful predictor of the clinical outcome of patients with non-valvular atrial fibrillation.

Changes in the Doppler myocardial performance index during dobutamine echocardiography: association with neurohormonal activation and prognosis after acute myocardial infarction

OBJECTIVES

To test whether an increase in Doppler myocardial performance index (MPI) during dobutamine stress echocardiography, reflecting deterioration of overall left ventricular function, is associated with increased N-terminal pro-brain natriuretic peptide (NT-pro-BNP) concentration and provides prognostic information beyond conventional systolic wall motion analysis after acute myocardial infarction (AMI).

DESIGN

Prospective, observational study.

METHODS

Dobutamine-atropine stress echocardiography (DASE) and NT-pro-BNP were assessed five days after AMI in 109 consecutive patients. MPI was measured at rest and at low-dose (10 microg/kg/min) and peak dobutamine infusion (<or= 40 microg/kg/min with or without atropine).

MAIN OUTCOME MEASURES

End point was a composite of cardiac death or readmission for heart failure or reinfarction.

RESULTS

In 35 patients (32%), MPI increased at low-dose DASE. This was associated with higher NT-pro-BNP concentrations (beta = 0.30, p = 0.004). During a mean follow up of 27 (SD 7) months, 8 patients died of cardiac causes and 15 patients were readmitted for heart failure or reinfarction. On Cox regression analysis, an increase in MPI at low-dose DASE (p = 0.02) was an independent predictor of cardiac events. In contrast, traditional wall motion analysis during DASE provided no additional prognostic information.

CONCLUSIONS

An increase in MPI at low-dose DASE, reflecting early deterioration of overall left ventricular function, is associated with raised NT-pro-BNP concentration and provides prognostic information beyond conventional stress echocardiographic data after AMI.

The Doppler myocardial performance index during low-dose dobutamine echocardiography predicts mortality and left ventricular dilation after a first acute myocardial infarction

BACKGROUND

Myocardial viability can be detected by wall motion analysis during low-dose dobutamine echocardiography (LDDE) after acute myocardial infarction (AMI). However, wall motion analysis describes only left ventricular (LV) systolic reserve. The Doppler myocardial performance index (MPI) is a quantitative measure of combined LV systolic and diastolic function. We hypothesized that an increase (deterioration) in MPI during LDDE, reflecting reduced systolic and diastolic LV reserve, could provide prognostic information beyond conventional systolic wall motion analysis on mortality, morbidity, and LV remodeling after AMI.

METHODS

Low-dose dobutamine echocardiography (10 microg/kg per minute) was performed within 24 hours and echocardiography was repeated 5 days and 1, 3, and 6 months after a first AMI in 162 consecutive patients. Patients were followed for 25 +/- 11 months. End points were all-cause mortality and cardiac events (cardiac death or readmission for heart failure or reinfarction).

RESULTS

In 72 (44%) patients, MPI increased during LDDE. This was independently associated with subsequent LV dilation at 6 months of follow-up (beta = .73, P < .0001). An increase in MPI during LDDE was a powerful prognostic indicator and remained a predictor of mortality (HR 1.92, 95% CI 1.36-2.71, P < .0001) and cardiac events (HR 2.45, 95% CI 1.83-3.27, P < .0001) after adjustment for clinical data, indices of LV function at rest, and wall motion analysis during LDDE.

CONCLUSIONS

Early after AMI, deterioration in MPI during LDDE predicts subsequent LV dilation and provides prognostic information incremental to clinical data, indices of LV function at rest, and conventional stress echocardiographic data.

Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women

OBJECTIVES

The objective of this study was to determine whether diastolic dysfunction is associated with increased risk of nonvalvular atrial fibrillation (NVAF) in older adults with no history of atrial arrhythmia.

BACKGROUND

Few data exist regarding the relationship between diastolic function and NVAF.

METHODS

The clinical and echocardiographic characteristics of patients age > or =65 years who had an echocardiogram performed between 1990 and 1998 were reviewed. Exclusion criteria were history of atrial arrhythmia, stroke, valvular or congenital heart disease, or pacemaker implantation. Patients were followed up in their medical records to the last clinical visit or death for documentation of first AF.

RESULTS

Of 840 patients (39% men; mean [+/- SD] age, 75 +/- 7 years), 80 (9.5%) developed NVAF over a mean (+/- SD) follow-up of 4.1 +/- 2.7 years. Abnormal relaxation, pseudonormal, and restrictive left ventricular diastolic filling were associated with hazard ratios of 3.33 (95% confidence interval [CI], 1.5 to 7.4; p = 0.003), 4.84 (95% CI, 2.05 to 11.4; p < 0.001), and 5.26 (95% CI, 2.3 to 12.03; p < 0.001), respectively, when compared with normal diastolic function. After a number of adjustments, diastolic function profile remained incremental to history of congestive heart failure and previous myocardial infarction for prediction of NVAF. Age-adjusted Kaplan-Meier five-year risks of NVAF were 1%, 12%, 14%, and 21% for normal, abnormal relaxation, pseudonormal, and restrictive diastolic filling, respectively. CONCLUSIONS; The presence and severity of diastolic dysfunction are independently predictive of first documented NVAF in the elderly.

Deceleration time of early filling in patients with left ventricular systolic dysfunction: functional and prognostic independent value

BACKGROUND

Although diastolic function parameters have been mentioned as significant predictors of functional capacity and prognosis in patients with left ventricular (LV) systolic dysfunction, it has not been fully elucidated whether they keep an independent predictive value when multiple parameters from a wide variety of examinations are considered.

METHODS

We prospectively studied 60 patients with New York Heart Association (NYHA) class II-IV chronic heart failure symptoms and LV ejection fraction <0.4. At the time of entry into the study, demographic data and functional class were obtained, and usual Doppler echocardiographic, radionuclide ventriculographic, cardiopulmonary exercise testing and hemodynamic variables were determined. Deceleration time of early filling (DT) and NYHA functional class were the only independent predictors of functional capacity as assessed by means of peak oxygen uptake (peak VO2). Mean follow-up was 21 +/- 6 months, and event-free survival was defined as the absence of cardiac death, urgent cardiac transplantation, or hospital admission requiring inotropic or mechanical support.

RESULTS

Multivariate Cox analysis showed that DT (P =.008), peak VO2 (P =.01), and NYHA class (P =.02) were independent predictors of event-free survival at 1 year. Patients in the lowest tertile of DT (<130 ms) had a significantly lower event-free survival than patients in the intermediate (44% vs 80%, P =.03) and in the highest tertile (44% vs 83%, P =.02). Patients with both a DT <130 milliseconds and a peak VO2 <14 mL/kg/min had the highest rate of events at 1 year (83% vs 22% for the remaining patients, relative risk 3.75, P <.001).

CONCLUSIONS

In patients with LV systolic dysfunction, DT is a powerful independent predictor of functional capacity and prognosis among a wide variety of variables. A shortened DT (<130 ms) identifies a subgroup of patients with a worse outcome, especially when combined with a reduced peak VO2 (<14 mL/kg/min).

Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study

OBJECTIVES

We sought to assess the prognostic value of left ventricular (LV) filling patterns, as determined by mitral E-wave deceleration time (DT) and color M-mode flow propagation velocity (Vp), on cardiac death and serial changes in LV volumes after a first myocardial infarction (MI).

BACKGROUND

Combined assessment of DT and Vp allows separation of the effects of compliance and relaxation on LV filling, thereby allowing identification of pseudonormal filling. This may be valuable after MI, where abnormal LV filling is frequently present.

METHODS

Echocardiography was performed within 24 h, five days and one and three months after MI in 125 unselected consecutive patients. Normal filling was defined as DT 140 to 240 ms and Vp > or =45 cm/s; impaired relaxation as DT > or =240 ms; pseudonormal filling as DT 140 to 240 ms and Vp <45 cm/s; and restrictive filling as DT <140 ms.

RESULTS

Left ventricular filling was normal in 38 patients; impaired relaxation in 38; pseudonormal in 23; and restrictive in 26. End-systolic and end-diastolic volume indexes were significantly increased during the first three months after MI in patients with pseudonormal or restrictive filling (37+/-15 vs. 47+/-19 ml/m2, p<0.0005 and 71+/-20 vs. 88+/-24 ml/m2, p<0.0005, respectively). During a follow-up period of 12+/-7 months, 33 patients died. Mortality was significantly higher in patients with impaired relaxation (p = 0.02), pseudonormal filling (p<0.00005) and restrictive filling (p<0.00005), compared with patients with normal filling. On Cox analysis, restrictive filling (p = 0.003), pseudonormal filling (p = 0.006) and Killip class > or =II (p = 0.008) independently predicted cardiac death, compared with clinical and echocardiographic variables.

CONCLUSIONS

Pseudonormal or restrictive filling patterns are related to progressive LV dilation and predict cardiac death after a first MI.

The echo-Doppler evaluation of left ventricular diastolic function. A current perspective

The role of left ventricular (LV) diastolic function in health and disease is still incompletely understood and under appreciated by most primary care physicians and many cardiologists. Physical examination, electrocardiogram, and chest radiographs are unreliable in making the diagnosis of LV diastolic dysfunction in most individuals, and invasive measurements of cardiac pressures, rates of LV relaxation, and LV compliance are costly, clinically impracticable as they carry increased risk, and require special catheters and software analysis programs. The authors address the definition of LV diastolic dysfunction, history of diastole, LV filling patterns, pulmonary venous flow velocity variables, additional ancillary data, practical echo-Doppler evaluation of LV diastolic function, and limitations.

Ratio of left ventricular peak E-wave velocity to flow propagation velocity assessed by color M-mode Doppler echocardiography in first myocardial infarction: prognostic and clinical implications

OBJECTIVES

To determine the ability of the ratio of peak E-wave velocity to flow propagation velocity (E/Vp) measured with color M-mode Doppler echocardiography to predict in-hospital heart failure and cardiac mortality in an unselected consecutive population with first myocardial infarction (MI).

BACKGROUND

Several experimental studies indicate color M-mode echocardiography to be a valuable tool in the evaluation of diastolic function, but data regarding the clinical value are lacking.

METHODS

Echocardiography was performed within 24 h of arrival at the coronary care unit in 110 consecutive patients with first MI. Highest Killip class was determined during hospitalization. Patients were divided into groups according to E/Vp <1.5 and > or =1.5.

RESULTS

During hospitalization 53 patients were in Killip class > or =II. In patients with E/Vp > or =1.5, Killip class was significantly higher compared with patients with E/Vp <1.5 (p < 0.0001). Multivariate logistic regression analysis identified E/Vp > or =1.5 to be the single best predictor of in-hospital clinical heart failure when compared with age, heart rate, E-wave deceleration time (Dt), left ventricular (LV) ejection fraction, wall motion index, enzymatic infarct size and Q-wave MI. At day 35 survival in patients with E/Vp <1.5 was 98%, while for patients with E/Vp > or =1.5, it was 58% (p < 0.0001). Cox proportional hazards model identified Dt <140 ms, E/Vp > or =1.5 and age to be independent predictors of cardiac death, with Dt < 140 ms being superior to age and E/Vp.

CONCLUSIONS

In the acute phase of MI, E/Vp > or =1.5 measured with color M-mode echocardiography is a strong predictor of in-hospital heart failure. Furthermore, E/Vp is superior to systolic measurements in predicting 35 day survival although Dt <140 ms is the most powerful predictor of cardiac death.