Assessment of left and right ventricular systolic and diastolic synchronicity in normal subjects by tissue Doppler echocardiography and the effects of age and heart rate

The reduction of the left ventricular long-axis early diastolic peak velocity (e') evident by early-middle age occurs in the absence of aging-related slowing of active relaxation

PURPOSE

A decrease in the left ventricular (LV) long-axis early diastolic peak velocity (e') is evident by early-middle age, but it is unknown to what extent this decrease is due to slowing of the speed of active relaxation versus a reduction in LV long-axis excursion during early diastole (EDExc).

METHODS

Pulsed-wave tissue Doppler imaging (TDI) signals were acquired from the septal and lateral borders of the mitral annulus in 62 healthy adult subjects of age 18-45 years. EDExc and LV systolic excursion (SExc) were measured as the integrals of the respective TDI signals. The speed of active relaxation was indirectly assessed using time interval measurements related to the TDI early diastolic signal, including the isovolumic relaxation time (IVRT'), the acceleration time (EDAT), and the duration (EDDur). Multiple linear regression analyses were performed to identify the relationships between e', age, EDExc, SExc, and time intervals.

RESULTS

The findings were similar for both LV walls. Age was negatively correlated with e' and EDExc, but was not correlated with SExc, IVRT', EDAT, or EDDur. The closest correlate of EDExc was SExc, and EDExc was independently correlated with both SExc and age. e' was also positively correlated with SExc, but the closest correlate of e' was EDExc, and when combined with EDExc, EDDur became an independent predictor of e'.

CONCLUSION

The aging-related decrease in e' evident by early-middle age occurs in the absence of aging-related slowing of active relaxation and therefore can be largely attributed to the accompanying reduction in EDExc.

A Comparative Study of Systolic and Diastolic Mechanical Synchrony in Canine, Primate, and Healthy and Failing Human Hearts

Aim: Mechanical dyssynchrony (MD) is associated with heart failure (HF) and may be prognostically important in cardiac resynchronization therapy (CRT). Yet, little is known about its patterns in healthy or diseased hearts. We here investigate and compare systolic and diastolic MD in both right (RV) and left ventricles (LV) of canine, primate and healthy and failing human hearts. Methods and Results: RV and LV mechanical function were examined by pulse-wave Doppler in 15 beagle dogs, 59 rhesus monkeys, 100 healthy human subjects and 39 heart failure (HF) patients. This measured RV and LV pre-ejection periods (RVPEP and LVPEP) and diastolic opening times (Q-TVE and Q-MVE). The occurrence of right (RVMDs) and left ventricular systolic mechanical delay (LVMDs) was assessed by comparing RVPEP and LVPEP values. That of right (RVMDd) and left ventricular diastolic mechanical delay (LVMDd) was assessed from the corresponding diastolic opening times (Q-TVE and Q-MVE). These situations were quantified by values of interventricular systolic (IVMDs) and diastolic mechanical delays (IVMDd), represented as positive if the relevant RV mechanical events preceded those in the LV. Healthy hearts in all species examined showed greater LV than RV delay times and therefore positive IVMDs and IVMDd. In contrast a greater proportion of the HF patients showed both markedly increased IVMDs and negative IVMDd, with diastolic mechanical asynchrony negatively correlated with LVEF. Conclusion: The present IVMDs and IVMDd findings have potential clinical implications particularly for personalized setting of parameter values in CRT in individual patients to achieve effective treatment of HF.

Right Ventricular Myocardial Stiffness and Relaxation Components by Kinematic Model-Based Transtricuspid Flow Analysis in Children and Adolescents with Pulmonary Arterial Hypertension

We hypothesized that the kinematic model-based parameters obtained from the transtricuspid E-wave would be useful for evaluating the right ventricular diastolic property in pediatric pulmonary arterial hypertension (PAH) patients. The model was parametrized by stiffness/elastic recoil k, relaxation/damping c and load x. These parameters were determined as the solution of m⋅d²x/dt² + c⋅dx/dt + kx = 0, which is based on the theory that the E-wave contour is determined by the interplay of stiffness/restoring force, damping/relaxation force and load. The PAH group had a significantly higher k and c compared with the control group (182.5 ± 72.4 g/s vs. 135.7 ± 49.5 g/s², p = 0.0232, and 21.9 ± 6.5 g/s vs. 10.6 ± 5.2 g/s, p <0.0001, respectively). These results indicate that in the PAH group, the right ventricle had higher stiffness/elastic recoil and inferior cross-bridge relaxation. The present findings indicate the feasibility and utility of using kinematic model parameters to assess right ventricular diastolic function.

Evaluation of left and right ventricular systolic and diastolic electromechanical synchrony in older people: a population-based observational study

It is unknown whether physiological ageing also goes along with electromechanical asynchrony of contraction. Aim of the study was to evaluate synchrony of contraction in older people with ("non-healthy") or without ("healthy") evidence for structural cardiac disease. In 547 persons (age 76.7+/-5.5 years, 306 male, 241 female) recruited from a population-based cohort of the ActiFE-Ulm study including a random sample of people >/=65 years old living in the region of Ulm, Germany, various PW- and TDI-Doppler based markers for asynchrony were obtained by echocardiography. Within a subgroup of 84 healthy subjects, at most minimal systolic and diastolic asynchrony was found. Concerning systolic asynchrony, similar observations were made within the non-healthy subgroup. However, extent of diastolic left ventricular intraventricular asynchrony and also - by tendency - diastolic interventricular asynchrony was increased in comparison to the healthy subgroup. To conclude, no evidence that physiological ageing might go along with relevant left or right ventricular systolic or diastolic electromechanical asynchrony was found in our study. Furthermore, our population-based data support the results from other clinical studies with rather selected cohorts that structural heart diseases might go along with increased diastolic asynchrony.

Left ventricular long axis tissue Doppler systolic velocity is independently related to heart rate and body size

Background

The physiological factors which affect left ventricular (LV) long-axis function are not fully defined. We investigated the relationships of resting heart rate and body size with the peak velocities and amplitudes of LV systolic and early diastolic long axis motion, and also with long-axis contraction duration.

Methods

Two groups of adults free of cardiac disease underwent pulsed-wave tissue Doppler imaging at the septal and lateral mitral annular borders. Group 1 (n = 77) were healthy subjects <50 years of age and Group 2 (n = 65) were subjects between 40–80 years of age referred for stress echocardiography. Systolic excursion (SExc), duration (SDur) and peak velocity (s') and early diastolic excursion (EDExc) and peak velocity (e') were measured.

Results

SExc was not correlated with heart rate, height or body surface area (BSA) for either LV wall in either group, but SDur was inversely correlated with heart rate for both walls and both groups, and after adjustment for heart rate, males in both groups had a shorter septal SDur. Septal and lateral s` were independently and positively correlated with SExc, heart rate and height in both groups, independent of sex and age. There were no correlations of heart rate, height or BSA with either e` or EDExc for either wall in either group.

Conclusion

Heart rate and height independently modify the relationship between s` and SExc, but neither are related to EDExc or e`. These findings suggest that s` and SExc cannot be used interchangeably for the assessment of LV long-axis contraction.

The effects of type 1 diabetes mellitus on cardiac functions in children: evaluation by conventional and tissue Doppler echocardiography

BACKGROUND

Several studies have pointed out the existence of cardiac dysfunction in patients with type 1 diabetes mellitus (DM) even in the absence of ischemic, valvular, or hypertensive heart disease. The present study evaluated cardiac dysfunction and the relationship between severity of disease and degree of cardiac dysfunction in children with type 1 DM.

METHODS

In this prospective study, 31 patients with type 1 DM and 33 sex- and age-matched healthy children were evaluated with conventional echocardiography and tissue Doppler echocardiography (TDE). A correlation between cardiac functions and glycated hemoglobin (HbA1C) was examined.

RESULTS

TDE results indicated that mitral valve early diastolic annular peak flow rate (E'), mitral valve systolic flow rate (S'), ratio of mitral valve early diastolic peak flow rate to mitral valve early diastolic annular peak flow rate (E/E'), and left ventricular (LV) myocardial performance index (MPI) were higher, and LV ejection time (ET) was shorter in patients with type 1 DM (p<0.05). In addition, tricuspid valve E' and right ventricular (RV) MPI were higher, while RV ET and tricuspid E/E' were lower in patients with type 1 DM compared to healthy children (p<0.05).

CONCLUSIONS

Although conventional echocardiography revealed no difference between patients with type 1 DM and healthy children, TDE showed dysfunctions of both ventricles. This state is closely related to degree of blood glucose level control. These findings signify diagnostic value of TDE in the early detection of cardiac effects among patients with type 1 DM.

Assessment of No-Reflow Phenomenon by Myocardial Blush Grade and Pulsed Wave Tissue Doppler Imaging in Patients with Acute Coronary Syndrome

Background:

No-reflow phenomenon is a complication of myocardial revascularization and it is associated with a worse prognosis.

Materials and Methods:

A prospective study was carried out enrolling patients with acute myocardial infarction (64 patients, 49 male and 15 female, median age 64.9 ± 10.61 years), both STEMI and NSTEMI, who underwent myocardial revascularization with percutaneous coronary intervention (PCI). TIMI flow and Myocardial Blush Grade (MBG) were assessed at baseline (T0), in addition to tissue Doppler imaging (TDI) and electrocardiogram. Cardiological evaluation was also performed at T1 (one month after PCI) and T2 (every year after revascularization for a mean follow-up of 24.9 months ± 6.93 months). Patients were divided into two groups on the basis of MBG.

Results:

In the present study, we found at T1 a significant association between MBG and dyslipidemia (P = 0,038) and NYHA class and MBG (P = 0,040), among clinical variables and cardiovascular risk factors. Moreover, a statistically significant relationship was observed between MBG and a new echocardiographic index of systolic and diastolic dysfunction, the EAS index measured with tissue Doppler imaging (P = 0,013). At T2, the EAS parameter was also significantly impaired in patients with reduced MBG, compared to patients with normal MBG (P = 0,003).

Conclusions:

This study demonstrates that the combined evaluation of systolic and diastolic dysfunction by EAS index, according to the literature, could detect a subclinical ventricular dysfunction due to a perfusion defect. Therefore, EAS index could be a useful parameter to be measured in the follow-up of patients undergoing revascularization.

Assessment of ventricular functions by tissue Doppler echocardiography in children with asthma

Patients with asthma develop pulmonary hypertension due to recurrent hypoxia and chronic inflammation, leading to right heart enlargement with ventricular hypertrophy. Patients with severe asthma can experience cor pulmonale later in life, but little is known about ventricular function during the early stages of the disease. This study aimed to investigate ventricular functions in asymptomatic children with asthma as detected by conventional echocardiography and tissue Doppler echocardiography (TDE). Fifty-one pediatric patients (mean age 10.4 ± 2.2 years) with asthma and 46 age- and sex-matched healthy children (mean age 10.9 ± 2.4 years) were studied. All subjects were examined by conventional echocardiography and TDE, and they had pulmonary function tests on spirometry. The right-ventricular (RV) wall was statistically (p = 0.01) thicker among asthmatic patients (4.7 ± 1.5 mm) compared with healthy children (3.6 ± 0.4 mm). However, conventional pulsed-Doppler indices of both ventricles did not differ significantly between asthmatic patients and healthy children (p > 0.05). The results of TDE examining RV diastolic function showed that annular peak velocity during early diastole (E'), annular peak velocity during late diastole (A') (16.4 ± 1.8 and 5.1 ± 1.4 cm/s, respectively), E'/A' ratio (3.2 ± 0.7), isovolumetric relaxation time (67.7 ± 10.2 ms) and myocardial performance index (48.1 % ± 7.0 %) of the lateral tricuspid annulus among asthmatic patients differed significantly (p = 0.01) from those of healthy children (13.2 ± 2.3, 8.2 ± 2.0 cm/s, 1.6 ± 0.5, 46.2 ± 8.7 ms, and 42.0 % ± 5.7 %, respectively). Only peak expiratory flow (PEF) rate from the pulmonary function tests was negatively correlated with the E'/A' ratio of the tricuspid annulus (r = -0.38, p = 0.01). This study showed that although the findings of clinical and conventional echocardiography were apparently normal in children with asthma, TDE showed subclinical dysfunction of the right ventricle, which is negatively correlated with PEF. These findings signify the diagnostic value of TDE in the early detection and monitoring of such deleterious effects among asthmatic patients.

Improved cardiac MRI volume measurements in patients with tetralogy of Fallot by independent end-systolic and end-diastolic phase selection

Objectives

To investigate to what extent cardiac MRI derived measurements of right ventricular (RV) volumes using the left ventricular (LV) end-systolic and end-diastolic frame misrepresent RV end-systolic and end-diastolic volumes in patients with tetralogy of Fallot (ToF) and a right bundle branch block.

Methods

Sixty-five cardiac MRI scans of patients with ToF and a right bundle branch block, and 50 cardiac MRI scans of control subjects were analyzed. RV volumes and function using the end-systolic and end-diastolic frame of the RV were compared to using the end-systolic and end-diastolic frame of the LV.

Results

Timing of the RV end-systolic frame was delayed compared to the LV end-systolic frame in 94% of patients with ToF and in 50% of control subjects. RV end-systolic volume using the RV end-systolic instead of LV end-systolic frame was smaller in ToF (median −3.3 ml/m², interquartile range −1.9 to −5.6 ml/m²; p<0.001) and close to unchanged in control subjects. Using the RV instead of LV end-systolic and end-diastolic frame hardly affected RV end-diastolic volumes in both groups and ejection fraction in control subjects (54±4%, both methods), while increasing ejection fraction from 45±7% to 48±7% for patients with ToF (p<0.001). QRS duration correlated positively with the changes in the RV end-systolic volume (p<0.001) and RV ejection fraction obtained in ToF patients when using the RV instead of the LV end-systolic and end-diastolic frame (p = 0.004).

Conclusion

For clinical decision making in ToF patients RV volumes derived from cardiac MRI should be measured in the end-systolic frame of the RV instead of the LV.

Tissue Doppler imaging predicts adverse outcome in children with idiopathic pulmonary arterial hypertension

OBJECTIVE

To evaluate the clinical utility of tissue Doppler imaging (TDI) in assessment of disease severity and prognostic value in children with idiopathic pulmonary arterial hypertension (PAH).

STUDY DESIGN

A prospective study was performed to evaluate TDI velocities (systolic myocardial velocity, early diastolic myocardial relaxation velocity [Em], late diastolic myocardial velocity associated with atrial contraction), brain natriuretic peptide, New York Heart Association (NYHA) functional class, and hemodynamics in 51 children (mean age; 11.6 years) with idiopathic PAH. Fifty-one healthy children with comparable demographics served as controls.

RESULTS

Em, Em/late diastolic myocardial velocity associated with atrial contraction ratio, and systolic myocardial velocity at mitral annulus, septum, and tricuspid annulus in PAH were significantly reduced compared with controls. Tricuspid Em had significant inverse correlations with plasma brain natriuretic peptide levels (r = -0.60, P < .001), right ventricular end-diastolic pressure (r = -0.79, P < .001), and mean pulmonary arterial pressure (r = -0.67, P < .001). Statistically significant differences were observed in tricuspid Em between NYHA functional class II vs combined III and IV (mean and SD; 11.9 ± 4.2 cm/s vs 8.2 ± 3.6 cm/s, respectively, P = .002). Cumulative event-free survival rate was significantly lower when tricuspid Em was ≤8 cm/s (log-rank test, P < .001)

CONCLUSIONS

Tricuspid Em velocity correlated with NYHA functional class as disease severity and may serve as a useful prognostic marker in children with idiopathic PAH. The present study is the initial report to evaluate TDI velocities against midterm outcome variables in a relatively large pediatric PAH population.

Fetal tissue Doppler imaging in pregnancies complicated with preeclampsia with or without intrauterine growth restriction

OBJECTIVES

This study's aim was to evaluate the effect of preeclampsia and intrauterine growth restriction (IUGR) on fetal cardiac function, and the relationship of the latter with adverse pregnancy outcomes.

MATERIAL AND METHODS

We did a cross-sectional study of 132 women with uncomplicated singleton pregnancies, 34 with preeclampsia without IUGR, and 12 with preeclampsia and IUGR. Fetal cardiac structure and function were evaluated using fetal two-dimension ultrasound, pulsed wave Doppler and tissue Doppler imaging (TDI). Data were analyzed by t-tests, ANOVA, Chi-square tests, or Wilcoxon rank-sum test.

RESULTS

Compared with the normal pregnancy group, mitral/tricuspid early systolic peak velocity of annulus/late diastolic peak velocity of annulus (Sa) and left ventricular (LV)/right ventricular (RV) early diastolic peak velocity at the annulus (Ea) in TDI decreased in preeclampsia with or without IUGR (P < 0.05). LV/RV Ea underwent a gestational decrease in preeclampsia with or without IUGR (P < 0.05). The changes in mitral/tricuspid Sa and LV Sa associated with preeclampsia were even more pronounced with preterm delivery at less than 34 gestational weeks and stillbirth (P < 0.05).

CONCLUSIONS

Intrauterine growth restriction influences fetal cardiac function in the presence of preeclampsia, and TDI may be a sensitive and preferable method to detect such changes. Fetal LV/RV Ea is a potential marker for early fetal cardiac diastolic impairment, and mitral/tricuspid Sa and LV Sa may be predictors for adverse pregnancy outcomes.

Assessment of cardiac functions using tissue Doppler imaging in children with familial Mediterranean fever

OBJECTIVE

Familial Mediterranean fever may carry a potential for cardiovascular disorders because of sustained inflammation during its course; however, there has been a limited number of studies investigating the cardiac functions in children. The aim of this study was to assess both ventricular diastolic functions using conventional echocardiography and tissue Doppler imaging in children with familial Mediterranean fever.

PATIENTS AND METHODS

The study population included 25 patients with familial Mediterranean fever - mean age was 11.8 plus or minus 5.30 years - and 23 healthy patients as controls - mean age was 9.88 plus or minus 3.69 years. Both ventricular functions were measured using echocardiography comprising standard M-mode and conventional Doppler and tissue Doppler imaging during an attack-free period.

RESULTS

The conventional echocardiographic parameters with myocardial performance index were in normal ranges and similar in patients with familial Mediterranean fever and controls, with a p-value more than 0.05. However, right ventricular diastolic dysfunction was observed in patients with familial Mediterranean fever documented by tissue Doppler imaging, with a p-value less than 0.05 for E't and A't wave ratio.

CONCLUSION

Using tissue Doppler imaging, we have demonstrated that although left ventricular functions were comparable in the patients and healthy children, right ventricular diastolic function indices were impaired in patients with familial Mediterranean fever during childhood. Impaired right ventricular diastolic function may be an early manifestation of cardiac involvement in children with familial Mediterranean fever.

Aerobic interval training compensates age related decline in cardiac function

OBJECTIVES

To study the effect of aerobic interval training (AIT) on myocardial function in sedentary seniors compared to master athletes (MA) and young controls.

DESIGN

Sixteen seniors (72 ± 1 years, 10 men) performed AIT (4 × 4 minutes) at ≈ 90% of maximal heart rate three times per week for 12 weeks. Results were compared with 11 male MA (74 ± 2 years) and 10 young males (23 ± 2 years).

RESULTS

Seniors had an impaired diastolic function compared to the young at rest. AIT improved resting diastolic parameters, increased E/A ratio (44%, p <0.01), early diastolic tissue Doppler velocity (e') (11%, p <0.05) and e' during exercise (11%, p <0.01), shortened isovolumic relaxation rate (IVRT) (13%, p <0.01). Left ventricle (LV) systolic function (S') was unaffected at rest, whereas S' during stress echo increased by 29% (p <0.01). Right ventricle (RV) S' and RV fractional area change (RFAC) increased (9%, p <0.01, 12%, p =0.01, respectively), but not RV e'. MA had the highest end-diastolic volume, stroke volume, diastolic reserve and RV S'.

CONCLUSION

AIT partly reversed the impaired age related diastolic function in healthy seniors at rest, improved LV diastolic and systolic function during exercise as well as RV S' at rest.

Cardiac functions in children with growth hormone deficiency before and during growth hormone-replacement therapy

Childhood growth hormone deficiency (GHD) decreases left-ventricular (LV) mass, but impairment of cardiac function has never been documented. The objective of this study was to assess the cardiac effects of GHD and recombinant human growth hormone (rhGH) treatment using conventional echocardiography and tissue Doppler imaging. Complete two-dimensional, M-mode, pulse-wave Doppler echocardiography and pulse-wave tissue Doppler imaging were performed in 12 children (6 male and 6 female patients) with GHD at baseline and at 5.86 ± 1.61 months after rhGH therapy. Recombinant human growth hormone treatment was associated with a significant increase in LV mass index (63.8 ± 27.1 to 79.3 ± 30.3 g/m(2); P < 0.01) and LV internal dimensions (21.4 ± 2.63 to 24.0 ± 4.13 mm in systole [P = 0.03] and 36.5 ± 3.90 to 39.5 ± 4.94 mm in diastole [P < 0.01]). There were statistical differences of parameters, such as deceleration time of early peak velocity of mitral, isovolumic relaxation time, and myocardial performance index (103 ± 15.4 to 139 ± 21.2 ms [P < 0.01], 55.5 ± 9.24 to 69.2 ± 3.74 ms [P < 0.01], and 37.8 ± 4.46 to 44.9 ± 5.44% [P < 0.01], respectively). Before and during rhGH therapy, there were no significant differences in fractional shortening of the left ventricle, peak mitral, and tricuspid wave velocities with ratios determined using conventional echocardiography and tissue Doppler imaging. In children, GHD affects heart morphology by inducing a decrease in cardiac size, but it does not modify cardiac function. Recombinant human growth hormone treatment increases cardiac mass, deceleration time of early peak velocity of the mitral valve, isovolumic relaxation time, and myocardial performance index, but it does not make a difference in other parameters of conventional echocardiography and tissue Doppler imaging.

Significance of electrocardiographic right bundle branch block in trained athletes

We sought to determine the clinical and physiologic significance of electrocardiographic complete right bundle branch block (CRBBB) and incomplete right bundle branch block (IRBBB) in trained athletes. The 12-lead electrocardiographic and echocardiographic data from 510 competitive athletes were analyzed. Compared to the 51 age-, sport type-, and gender-matched athletes with normal 12-lead electrocardiographic QRS complex duration, the 44 athletes with IRBBB (9%) and 13 with CRBBB (3%) had larger right ventricular (RV) dimensions, as measured by the basal RV end-diastolic diameter (CRBBB 43 ± 3 mm, IRBBB 38 ± 6 mm, normal QRS complex 35 ± 4 mm, p <0.001) and RV end-diastolic area (CRBBB 33 ± 5, IRBBB 27 ± 7, and normal QRS complex 23 ± 3 cm(2); p <0.001). Athletes with CRBBB also had a relative reduction in the RV systolic function at rest as assessed by the RV fractional area change and peak systolic tissue velocity. Finally, QRS prolongation was associated with parallel increases in interventricular dyssynchrony (basal RV to basal lateral left ventricular peak systolic tissue velocity time difference: CRBBB 112 ± 15, IRBBB 73 ± 33, normal QRS complex 43 ± 39 ms, p <0.001). Despite these findings, no athlete with CRBBB or IRBBB was found to have pathologic structural cardiac disease. In conclusion, among trained athletes, CRBBB and IRBBB appear to be markers of a structural and physiological cardiac remodeling triad characterized by RV dilation, a relative reduction in the RV systolic function at rest, and interventricular dyssynchrony.

Evaluation of left ventricular synchronicity in hypertensive patients with overweight or obesity

The left ventricular synchronicity in hypertensive patients with overweight or obesity has not been well elucidated. This study was designed to evaluate the left ventricular synchronicity in these patients. Tissue Doppler imaging was performed in 126 hypertensive patients and 25 control subjects. The hypertensive patients were divided into three groups according to BMI: normal weight group (BMI <25 kg/m(2), n = 32, H-NW group), overweight group (BMI 25-29.9 kg/m(2), n = 64, H-OW group), and obese group (BMI >or=30 kg/m(2), n = 30, H-OB group). Left ventricular systolic and diastolic synchronicity were determined by measuring the maximal differences in time to peak myocardial systolic contraction (T(s)-diff) and early diastolic relaxation (T(e)-diff) between any two of the left ventricular segments and the standard deviation of time to peak myocardial systolic contraction (T(s)-SD) and early diastolic relaxation (T(e)-SD) of all 12 segments. Compared with the control group, the indexes of synchronicity including T(s)-diff, T(s)-SD, T(e)-diff, and T(e)-SD were significantly prolonged in the hypertensive patients. Furthermore, although the indexes of blood pressure had no difference among the hypertensive groups, the impaired systolic and diastolic synchronicity including T(s)-diff, T(s)-SD, and T(e)-SD was obviously aggravated with the increasing BMI. Stepwise multivariate analysis revealed BMI as an independent predictor of T(s)-SD and T(e)-SD. Therefore, the impairment of left ventricular synchronicity was aggravated with increasing BMI in hypertensive patients. Overweight and obesity may be important factors to impact the left ventricular synchronicity.

Ventricular asynchrony of time-to-peak systolic velocity in structurally normal heart by tissue Doppler imaging

BACKGROUND

Echocardiographic measurements of time-to-peak systolic velocities (Ts) are helpful for assessing the degree of cardiac asynchrony. We assessed the degree of ventricular asynchrony in structurally normal heart according to Ts by tissue Doppler imaging.

METHODS

We performed conventional echocardiography and tissue velocity imaging for 65 healthy adult volunteers to measure the Ts of 12 left ventricular segments in the mid and basal levels delay of Ts and standard deviation (SD) of Ts in all and basal segments. Six frequently used markers of dyssynchrony were measured and were also compared between men and women. Data are presented as median (25th and 75th percentile).

RESULTS

Septal-lateral and anteroseptal-posterior delays were 50 (20, 90) and 20 (0, 55) ms. The delay between the longest and the shortest Ts in basal and all segments were 100 (80, 120) and 110 (83, 128) ms, respectively. SD of Ts was 39 (24, 52) ms for basal and 41 (28, 51) ms for all segments. Overall, 76.9% of cases had at least one marker of dyssynchrony. Frequencies of dyssynchrony markers were almost significantly higher in women compared to men. The most frequently observed dyssynchrony marker was SD of Ts of all segments (70.8%) and the lowest was anteroseptal-posterior delay (21.5%).

CONCLUSIONS

Normal population almost had dyssynchrony by previously described markers and many of these markers were more frequent in women. Conducting more studies on normal population by other tissue Doppler modalities may give better description of cardiac synchronicity.

Diagnostic approaches for diabetic cardiomyopathy and myocardial fibrosis

In diabetes mellitus, alterations in cardiac structure/function in the absence of ischemic heart disease, hypertension or other cardiac pathologies are termed diabetic cardiomyopathy. In the United States, the prevalence of diabetes mellitus continues to rise and the disease currently affects about 8% of the general population. Hence, the use of appropriate diagnostic strategies for diabetic cardiomyopathy, which may help correctly identify the disease at early stages and implement suitable corrective therapies is imperative. Currently, there is no single diagnostic method for the identification of diabetic cardiomyopathy. Diabetic cardiomyopathy is known to induce changes in cardiac structure such as, myocardial hypertrophy, fibrosis and fat droplet deposition. Early changes in cardiac function are typically manifested as abnormal diastolic function that with time leads to loss of contractile function. Echocardiography based methods currently stand as the preferred diagnostic approach for diabetic cardiomyopathy, due to its wide availability and economical use. In addition to conventional techniques, magnetic resonance imaging and spectroscopy along with contrast agents are now leading new approaches in the diagnosis of myocardial fibrosis, and cardiac and hepatic metabolic changes. These strategies can be complemented with serum biomarkers so they can offer a clear picture as to diabetes-induced changes in cardiac structure/function even at very early stages of the disease. This review article intends to provide a summary of experimental and routine tools currently available to diagnose diabetic cardiomyopathy induced changes in cardiac structure/function. These tools can be reliably used in either experimental models of diabetes or for clinical applications.

Three-dimensional-wall motion tracking: a new and faster tool for myocardial strain assessment: comparison with two-dimensional-wall motion tracking

BACKGROUND

Two-dimensional (2D) wall motion-tracking echocardiography (WMT) is a useful method to measure myocardial strain, but it is very limited because acquisition and analysis are time consuming. Three-dimensional (3D) WMT is a new method that might improve diagnostic usefulness and reduce study times. The aims of this study were to compare results on 2D and 3D WMT and to compare the times for the acquisition and analysis of regional myocardial strain between the two methods.

METHODS

Measurements of the radial and longitudinal strain of every left ventricular (LV) segment and the time for acquisition and analysis were obtained using 3D and 2D WMT.

RESULTS

Thirty patients were enrolled (mean age, 57.2 +/- 19.6 years; 60% men). Three-dimensional WMT provided complete radial and longitudinal LV strain information, similar to 2D WMT (P = NS), but it was less time consuming: the times for acquisition and analysis were 14.0 +/- 1.9 minutes with 2D WMT and 5.1 +/- 1.1 minutes with 3D WMT (P < .001). Furthermore, in the same analysis, a greater number of segments could be analyzed using 3D WMT (72.4%) compared with 2D WMT (52.0%).

CONCLUSIONS

Three-dimensional WMT provides a faster, more complete, and similar analysis to assess LV longitudinal and radial strain compared with 2D WMT. Thus, 3D WMT is a potential clinical bedside tool for quantifying myocardial strain.

Effect of extreme exercise on myocardial function as assessed by tissue Doppler imaging

BACKGROUND

Response of the human heart to exercise has been studied extensively, but little information is available on the effects of exhaustive exercise on cardiac performance.

OBJECTIVES

The aim of this study was to evaluate the effect of severe prolong exercise on both left and right ventricular performance. To maximize the sensitivity of our study we used tissue Doppler imaging.

METHODS

Participants in army ranger training program were invited to participate in this prospective study. All patients underwent transthoracic echocardiography using tissue Doppler imaging before and after Ranger training program.

RESULTS

A total of 45 consecutive male rangers who completed 8 weeks of training were included in this study. Peak systolic myocardial velocity (S) decreased significantly after training (12.46 +/- 0.54 vs. 9.93 +/- 0.45 cm/s; P < 0.001). In the right ventricle, tissue Doppler measures of systolic and early diastolic function decreased significantly after training compared to pretraining values.

CONCLUSION

In conclusion, very strenuous prolonged exercise may result in depressed left ventricular contractile function. This raises the possibility of cardiac fatigue.

Assessment of left ventricular dyssynchrony and function using real-time 3-dimensional echocardiography in patients with congenital right heart disease

BACKGROUND

Patients after repair of congenital right heart disease (CRHD) may exhibit left ventricular (LV) dyssynchrony (LVD). However, the diagnosis of LVD is difficult and its reliability limited because current methods do not assess LVD of the whole LV simultaneously. The aim of the study was to assess LVD according to a novel global systolic dyssynchrony index (SDI) derived from real-time 3-dimensional echocardiography in patients after repaired CRHD.

METHODS

Two-dimensional echocardiography and real-time 3-dimensional echocardiography were performed in 30 patients after CRHD repair and in 30 matched healthy controls. Real-time 3-dimensional echocardiography data sets provided time-volume curves, and 2 global SDIs were derived from the dispersion of time to reach minimal systolic volume according to a 16- or 17-LV segment model.

RESULTS

Both SDIs were significantly elevated in the patient as compared with the control group (P < .001). A cutoff value for both SDIs was calculated and LVD defined as one of the SDIs exceeding cutoff. Left ventricular dyssynchrony was present in 5 (100%) of 5 patients with a LV ejection fraction (EF) <50% and 13 (52%) of 25 patients with preserved LVEF, thus being diagnosed in a total of 18 (60%) of 30 patients. Moreover, patients with LVD showed a significantly higher degree of pulmonary regurgitation (P = .01) with elevated right ventricular volumes and altered septal motion. Stepwise multivariate analysis identified LVEF (P = .005) and the degree of pulmonary regurgitation (P = .02) as independent predictors of LVD.

CONCLUSIONS

Left ventricular dyssynchrony can be detected in about 60% of patients after CRHD repair and is mainly due to significant pulmonary regurgitation resulting in an altered septal motion and systolic LV function.

Relation between left ventricular regional radial function and radial wall motion abnormalities using two-dimensional speckle tracking in children with idiopathic dilated cardiomyopathy

Left ventricular (LV) regional radial function and its relation to radial wall motion abnormalities have not been investigated in children with idiopathic dilated cardiomyopathy (IDC). Radial strain was measured using 2-dimensional speckle tracking to evaluate regional radial function and wall motion in 6 LV segments in 24 children (0 to 18 years old) with IDC and 16 healthy controls. Patients and controls were similar in age. Patients with IDC had higher heart rates (97 +/- 28 vs 77 +/- 19, p <0.05) and decreased ejection fraction (34 +/- 12% vs 66 +/- 7%, p <0.0001) compared with controls. Radial strain in all segments was significantly lower in patients with IDC. In IDC, average radial strain correlated well with ejection fraction (r = 0.8, p <0.0001). The SD of time to peak radial strain among 6 LV segments was significantly higher in patients with IDC than in controls (56 +/- 38 vs 15 +/- 12 ms, p <0.0001). Segmental peak radial strain correlated closely to time to peak radial strain in controls (r = 0.98, p = 0.0008), but less in patients with IDC (r = 0.76, p = 0.07). In conclusion, LV regional radial function is impaired in pediatric IDC, in association with increased radial dyssynchrony, revealing a possible important mechanism for LV dysfunction in these children.

The Mitral Annular Middiastolic Velocity Curve: Functional Correlates and Clinical Significance in Patients with Left Ventricular Hypertrophy

BACKGROUND

Little is known regarding the tissue Doppler characteristics and clinical significance of mitral annular motion during diastasis (L' wave).

METHODS

In consecutive patients with left ventricular hypertrophy and normal ejection fraction, standard Doppler and Doppler tissue imaging were performed. Patients were followed up for heart failure (HF) hospitalization.

RESULTS

Of 177 patients, 53 (30%) had an L', detected most frequently at the lateral mitral annulus, whereas 35 (20%) had middiastolic transmitral flow (L wave), which almost invariably coexisted with the L'. The L' predicted increased left ventricular filling pressure with 74% sensitivity and 82% specificity, and increased risk of future HF (hazard ratio 3.9 [P = .030]), even after adjusting for baseline clinical differences (hazard ratio 6.5 [P = .024]). When associated with an L wave, HF risk increased further.

CONCLUSIONS

Middiastolic annular motion, detectable in almost a third of patients with left ventricular hypertrophy, may be an early marker of diastolic dysfunction and a prognostic marker for HF.

Using echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy has become a therapeutic option for refractory heart failure. Several imaging techniques play an increasingly important role in patient selection during and after implantation. This manuscript reviews the current echocardiographic techniques available for guiding both patient selection and optimization of device programming following implantation.

Can Transesophageal Pulse-Wave Tissue Doppler Imaging Be Used to Evaluate Left Ventricular Function?

BACKGROUND

This study aimed to evaluate the efficiency of transesophageal tissue Doppler echocardiography (TDE) in evaluation of the left ventricular functions. To this end, the data obtained by transoesophageal tissue Doppler echocardiography and by transthoracic tissue Doppler echocardiography were compared simultaneously.

METHODS

Nineteen consecutive patients (7 female and 12 male) underwent a clinically indicated study. In transthoracic (TTE) and transoesophageal (TEE) echocardiographic study, a Vingmed System Five Doppler echocardiographic unit (GE Vingmed) was used. For the assessment of the left ventricular function using transthoracic and transoesophageal TDE, the mitral annular peak systolic (S), early diastolic (E), late diastolic velocities (A), late to early velocity ratio (E/A), deceleration times (DT), left ventricular isovolumetric relaxation times (IVRT) were measured at the lateral, medial, anterior, and posterior corners at the mitral annulus by activating TDE mode in the transthoracic and transoesophageal apical four- and two-chamber view. Bland-Altman plots were used to compare the two measurement techniques. The differences between the groups were assessed by Mann-Whitney U test. All the data were expressed as mean +/- SD. A P-value of <0.05 was considered significant.

RESULTS

There were no significant differences between two techniques in terms of blood pressure and heart rate. Two techniques were compared for the transthoracic and transoesophageal TDE parameters. Bland-Altman analysis showed comparable values for E, A, E/A, S, and mE/E, although the measurements of DT and IVRT were different.

CONCLUSION

PW tissue Doppler echocardiographic approach during TEE may be suitable for assessment of the left ventricular function.

Concordance Between Mechanical and Electrical Dyssynchrony in Heart Failure Patients: A Function of the Underlying Cardiomyopathy?

BACKGROUND

Cardiac resynchronization therapy (CRT) improves heart failure (HF) symptoms through a reduction of cardiac mechanical dyssynchrony. Mechanical dyssynchrony is currently estimated by electrical dyssynchrony (QRS duration). It is known that electrical and mechanical dyssynchrony are not well correlated in HF patients. However, there is limited information about whether this relationship might be influenced by the underlying cardiomyopathy.

METHODS

Doppler echocardiography was performed in 88 patients presenting with heart failure due to ischemic (n = 42) or nonischemic (n = 46) heart disease, left ventricular ejection fraction <40%, New York Heart Association class II-IV, regardless of their QRS duration. Interventricular dyssynchrony was assessed by the time interval between preaortic and prepulmonary ejection times. Intraventricular dyssynchrony was ascertained by (1) the delay between the earliest and the latest peak negative longitudinal strain recorded in the basal and mid-segments of the lateral and septal walls (TMinMax) and (2) the standard deviation of time-to-peak in the same segments (SDdys).

RESULTS

The correlation coefficient between QRS duration and mechanical interventricular dyssynchrony was r = 0.47 (P < 0.001) in patients with nonischemic disease and nonsignificant in patients with ischemic disease. Similarly, the correlation coefficient between QRS duration and mechanical intraventricular dyssynchrony was significant in patients with nonischemic disease (r = 0.37, P = 0.01 for TMinMax; r = 0.42, P = 0.003 for SDdys) and nonsignificant in patients with ischemic disease.

CONCLUSION

The concordance between electrical dyssynchrony assessed by QRS duration and mechanical dyssynchrony assessed by myocardial strain is dependent upon the underlying cardiomyopathy. This observation may improve our understanding of the various responses observed in CRT patients.

Relationship between Relative Aerobic Power and Echocardiographic Characteristics in Male Athletes

The relationship between relative aerobic power (rel.VO(2)max) as a generally accepted indicator of endurance capacity and certain characteristics of the athlete's heart, such as body-size related (relative) left ventricular (LV) diastolic wall thickness (WTd), internal diameter (LVIDd), muscle mass (MM), WTd/IDd, heart rate (HR), fractional shortening (FS) and E/A ratio, were investigated in 346 young males (18-35 years, 291 athletes of various events and 55 nonathletic control subjects). Rel.VO(2)max was measured by spiroergometry; cardiac characteristics were determined by two-dimensionally guided M-mode and Doppler-echocardiography. When the groups were pooled, correlation of rel.VO(2)max with the cardiac parameters was significant: LVMM.BSA(-1.5)= 0.413, LVWTd.BSA(-0.5)= 0.327, LVIDd.BSA(-0.5)= 0.292, HR =-0.434, E/A = 0.272 (P < 0.001), but no significant relationship was seen with FS and WTd/IDd. In the endurance trained group, rel. VO(2)max correlated significantly with LVMM.BSA(-1.5), LVWT.BSA(-0.5), HR, and E/A, in the ballgame players with LVMM.BSA(-1.5), LVWT.BSA(-0.5), and E/A, in the power-and-sprint event athletes with HR and E/A. In the control group, no significant relationship was observed. Results indicate that in athletes having higher endurance capacity maximal oxygen consumption depends largely on cardiac condition, while in athletes with a lower endurance capacity it can be limited by peripheral conditions.

Right Ventricular Mechanical Dyssynchrony in Children with Hypoplastic Left Heart Syndrome

BACKGROUND

Mechanical dyssynchrony predicts response to cardiac resynchronization therapy in adults with heart failure. Children with hypoplastic left heart syndrome (HLHS) are susceptible to right ventricular (RV) failure; however, mechanical dyssynchrony has not been studied in this population with newly available methodologies. We investigated RV mechanical dyssynchrony in children with HLHS using vector velocity imaging.

METHODS

We used vector velocity imaging to quantify the SD of time to peak velocity, strain, and strain rate among 6 RV segments to define intraventricular RV synchrony in 16 children with HLHS and RV and left ventricular (LV) synchrony in 16 healthy age-matched control subjects. We further investigated relations between QRS duration and mechanical dyssynchrony and between mechanical dyssynchrony and systolic function.

RESULTS

Children with HLHS had significant RV mechanical dyssynchrony versus LV and RV control subjects (strain 37 +/- 35 vs 8 +/- 8 milliseconds, P = .003 [LV], 9 +/- 11 milliseconds, P = .005 [RV]; strain rate 31 +/- 37 vs 10 +/- 13 milliseconds, P = .04 [LV], 14 +/- 15 milliseconds, P = .09 [RV]). There was no significant relationship between QRS duration and mechanical dyssynchrony and no obvious relation between the degree of mechanical dyssynchrony and the RV fractional area of change.

CONCLUSIONS

Children with HLHS have RV mechanical dyssynchrony unrelated to surface electrocardiographic QRS duration. This may contribute to RV dysfunction and may indicate the usefulness of cardiac resynchronization therapy in this population.

Effect of Heart Rate on Tissue Doppler Measures of Diastolic Function

BACKGROUND

Our aim was to study the independent effect of heart rate (HR) on parameters of diastolic function, particularly mitral annular velocities measured by tissue Doppler imaging (TDI), an effect which is not well understood.

METHODS

Sixteen patients with dual chamber pacemakers attending for routine pacemaker review underwent detailed echocardiographic assessment during atrial pacing with intact atrioventricular conduction at baseline and accelerated HRs. Mitral inflow and annular tissue Doppler velocities and systolic strain parameters were compared.

RESULTS

Parameters of systolic function were unaffected by increased HR. When these parameters were compared at baseline (mean 67 bpm) and accelerated HR (mean 80 bpm), the following was observed: a significant decrease in early mitral inflow (E) wave (70.5 +/- 5.5 cm/s vs 63.5 +/- 4.9 cm/s, P < 0.02) and early mitral annular (E') velocities (7.0 +/- 0.5 cm/s vs 6.3 +/- 0.6 cm/s, P < 0.003) and a significant increase in mitral inflow A wave (70.3 +/- 4.5 cm/s vs 77.3 +/- 4.4 cm/s, P < 0.05) and late mitral annular (A') velocities (9.3 +/- 0.6 cm/s vs 10.8 +/- 0.5, P < 0.00004).

CONCLUSION

Changes in HR have previously unrecognized significant effects on tissue Doppler parameters of diastolic function. Further study is required to determine if tissue Doppler derived annular velocities should be corrected for HR.

Prognostic values of B-type natriuretic peptide in severe sepsis and septic shock

OBJECTIVE

To investigate the changes in B-type natriuretic peptide concentrations in patients with severe sepsis and septic shock and to investigate the value of B-type natriuretic peptide in predicting intensive care unit outcomes.

DESIGN

Prospective observational study.

SETTING

General intensive care unit.

PATIENTS

Forty patients with severe sepsis or septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

B-type natriuretic peptide measurements and echocardiography were carried out daily for 10 consecutive days. In-hospital mortality and length of stay were recorded. The admission B-type natriuretic peptide concentrations were generally increased (747 +/- 860 pg/mL). B-type natriuretic peptide levels were elevated in patients with normal left ventricular systolic function (568 +/- 811 pg/mL), with sepsis-related reversible cardiac dysfunction (630 +/- 726 pg/mL), and with chronic cardiac dysfunction (1311 +/- 1097 pg/mL). There were no significance changes in B-type natriuretic peptide levels over the 10-day period. The daily B-type natriuretic peptide concentrations for the first 3 days neither predicted in-hospital mortality nor correlated with length of intensive care unit or hospital stay.

CONCLUSION

B-type natriuretic peptide concentrations were increased in patients with severe sepsis or septic shock regardless of the presence or absence of cardiac dysfunction. Neither the B-type natriuretic peptide levels for the first 3 days nor the daily changes in B-type natriuretic peptide provided prognostic value for in-hospital mortality and length of stay in this mixed group of patients, which included patients with chronic cardiac dysfunction.

Tissue Doppler imaging a new prognosticator for cardiovascular diseases

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.

Quantification of Global Left Ventricular Systolic Dysfunction in Patients with Coronary Artery Disease by Pulsed Doppler Tissue Imaging: The Value of Mitral Annulus Time Intervals

BACKGROUND

Mitral annulus systolic velocity measured by Doppler tissue imaging (DTI) offers an alternate method for assessment of global left ventricular systolic function. However, there has been no study correlating mitral annulus systolic time intervals with left ventricular ejection fraction (LVEF).

METHODS

Patients with angina pectoris (AP, 16 cases) and prior myocardial infarction (MI, 34 cases) were studied by pulsed DTI. Sixteen age-matched normal subjects served as controls. The septum, lateral, anterior, and inferior walls of the mitral annulus were selected for DTI sampling. Time to peak of the systolic mitral annular wave (TS) and regional preejection period (PEP) were measured.

RESULTS

PEP and TS were significantly longer in the MI group than that in the control and the AP groups. Both PEP and TS at all the annular sites and their two-site averages had significantly negative correlations with LVEF (r =-0.62 to -0.68 and -0.49 to -0.62; P < 0.001, respectively).

CONCLUSION

PEP and TS as measured by pulsed DTI may be promising indexes for the quantitative assessment of global left ventricular systolic dysfunction in patients with coronary artery disease.

Abnormal Tissue Doppler Images are Associated With Elevated Plasma Brain Natriuretic Peptide and Increased Oxidative Stress in Acute Kawasaki Disease

BACKGROUND

The aims of this study were to evaluate myocardial mechanics using pulsed tissue Doppler imaging (TDI), and to determine the relationship between abnormal myocardial performance and plasma brain natriuretic peptide (BNP) levels and oxidative stress in acute Kawasaki disease (KD).

METHODS AND RESULTS

Consecutive TDI parameters, including peak systolic velocity (Sw) and early (Ew) and late diastolic excursion of the mitral annuli were obtained in 42 patients with KD (mean age: 2.4+/-0.4 years) in weeks 1, 2, and 3, and during convalescence. Plasma BNP level and urinary 8-isoprostane were also examined during the acute phase. These data were then compared with TDI profiles from 62 healthy children, plasma BNP levels in 38 controls with other febrile illnesses, and urinary 8-isoprostane levels in 13 healthy children. Ew in week 1 was significantly lower than in controls, subsequently normalizing in the convalescent stage. Plasma BNP level in acute KD patients was significantly higher (65+/-9 pg/ml) than in controls (13+/-2 pg/ml). Urinary 8-isoprostane level in acute KD patients was significantly higher as compared with control (596 +/-37 vs 379+/-26 pg/ml Cr, p<0.05). There was a significant negative correlation between week 1 Sw and plasma BNP level (r=-0.55, p=0.0001). Change in Sw velocity in the BNP >/=51 group was significantly greater than in the BNP <51 group. There was a significant negative correlation between week 1 Sw and urinary 8-isoprostane level (r=-0.48, p=0.001).

CONCLUSIONS

Latent abnormal tissue Doppler profiles, possibly reflecting long-axis systolic and diastolic dysfunction have been noted in KD patients. Abnormal myocardial mechanics may contribute to the increased plasma BNP level and enhanced oxidative stress may contribute to cardiac dysfunction in KD.