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

Coronary ectasia is associated with impaired left ventricular myocardial performance in patients without significant coronary artery stenosis

OBJECTIVES

To determine both ventricular functions and tissue Doppler echocardiography (TDE)-derived myocardial performance index (MPI) in patients with coronary artery ectasia (CAE).

SUBJECTS AND METHODS

Twenty-five patients with CAE (13 men; mean age 57 ± 9 years) and 25 age- and sex-matched controls without CAE (8 men; mean age 54 ± 10 years) were enrolled in the study. Left and right ventricular functions were detected using conventional echocardiography and TDE.

RESULTS

Left ventricle-lateral wall (0.61 ± 0.17; 0.50 ± 0.10, p = 0.02), interventricular septum (0.66 ± 0.17; 0.52 ± 0.10, p = 0.007) and mean MPI (0.63 ± 0.15; 0.51 ± 0.09, p = 0.004) were increased in the CAE group compared to the control group. Right ventricular MPI was similar in both the CAE and control groups (0.58 ± 0.18; 0.52 ± 0.19, p > 0.05).

CONCLUSION

The findings show that left ventricular MPI is different in CAE patients without obstructive coronary artery disease compared to the normal control group. Also in these patients, right ventricular MPI was similar to the control group.

Usefulness of plasma brain natriuretic peptide measurement and tissue Doppler imaging in identifying isolated left ventricular diastolic dysfunction without heart failure

Left ventricular (LV) diastolic dysfunction carries a substantial risk for the subsequent development of heart failure and reduced survival, even when it is asymptomatic. Plasma brain natriuretic peptide (BNP) level and tissue Doppler imaging indexes provide powerful incremental assessment of LV diastolic function. Accordingly, the aim of this study was to clarify whether these methodologies could identify LV diastolic dysfunction without heart failure in 280 patients with preserved LV ejection fractions (> or =50%) who underwent echocardiography and cardiac catheterization for the evaluation of coronary artery disease. Patients were classified into 2 groups, those with diastolic dysfunction (tau > or =48 ms; n = 91) and those with normal diastolic function (tau <48 ms; n = 189). Plasma BNP > or =22.4 pg/ml, an unexpectedly low value, had sensitivity of 74.7% and specificity of 60.8% for identifying isolated LV diastolic dysfunction; the combined use of BNP > or =22.4 pg/mL and mitral annular velocity during early diastole <7.4 cm/s had relatively low sensitivity of 44.0% but high specificity of 86.8%. In conclusion, using plasma BNP level and with the combination of BNP level and mitral annular velocity during early diastole, invasively proved isolated LV diastolic dysfunction without heart failure could be identified in patients with coronary artery disease.

Assessment of left ventricular functions in patients with isolated coronary artery ectasia by conventional and tissue Doppler imaging

The authors sought to determine left ventricular functions by conventional and tissue Doppler imaging in patients with isolated coronary artery ectasia and controls. Peak early (E) and late (A) mitral inflow velocity, E/A ratio, E deceleration time, and isovolumetric relaxation time were obtained. Peak systolic velocity (Sm), diastolic early (Em), and late (Am) velocities were measured by tissue Doppler imaging. Interventricular septum velocities, including peak systolic (Ss), diastolic early (Es), and late (As) velocities, were recorded. Peak early (E) velocity, E/A ratio, and E deceleration time were different in both groups. Isovolumetric relaxation time was prolonged in patients with coronary artery ectasia than controls. Em and Em/Am ratio were lower in patients with coronary artery ectasia than controls. Diastolic early and Es/As velocities were lower in patients with coronary artery ectasia compared with controls. The authors showed that mitral inflow-lateral annulus and interventricular septum velocities were lower in patients with coronary artery ectasia than controls indicating left ventricular diastolic dysfunction.

Left ventricle diastolic function in the patients after coronary arteries bypass graft combined with left ventricle aneurismectomy according to tissue doppler imaging: one year follow-up

AIM

To evaluate left ventricle (LV) diastolic function dynamics in patients after acute myocardial infarction (AMI) after combined operation of coronary artery bypass graft with LV aneurismectomy (CABG + AE) according to the results of tissue Doppler imaging (TDI).

METHODS

Forty patients after AMI underwent Doppler echocardiography (EchoCG) with TDI and M-mode colour-flow imaging before and in 3 and 12 months after CABG + AE. Mitral annulus (MA) TDI with velocity indices was performed in 4 segments of LV.

RESULTS

Conventional transmitral diastolic Doppler indices before and after CABG + AE remained unchanged. TDI showed significant improvement of LV systolic (systolic movement velocity S: 6.1+/-0.8, 7.4+/-1.2 and 6.9+/-1.3 cm/sec. before and in 3 and 12 months after the operation, respectively, p<0.01) and diastolic function after the operation (MA early diastolic movement velocity (e'): 7.3 +/- 2.1, 8.4 +/- 1.5 and 8.9 +/- 1.8 cm/s.; ratio of transmitral early-flow velocity (E) to MA early-diastolic movement velocity (E/e'): 18.4 +/- 2.2, 12.3 +/- 1.8 and 11.5 +/- 2.3; ratio of E diastolic flow propagation velocity (Vp) 3.1 +/- 0.45, 2.2 +/- 0.38 and 1.8 +/- 0.16 before and in 3 and 12 months after the operation, respectively, p<0.01).

CONCLUSIONS

Results of the study demonstrate significant improvement of LV diastolic function in the patient after CABG + AE according to TDI, regardless of transmitral flow pattern. TDI is more sensitive and preload independent method of LV myocardial function evaluation.

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.

Use of noninvasive tools in primary pulmonary hypertension to assess the correlation of right ventricular function with functional capacity and to predict outcome

Most patients with Primary Pulmonary Hypertension (PPH) have severe exertional limitation which ultimately leads to right heart failure and death. The purpose of the study was to assess the correlation between right ventricular (RV) systolic and diastolic noninvasive variables and exercise tolerance, as well as the predictors of adverse outcome in treated patients.

METHODS

We prospectively studied 29 patients, 17 with PPH and 12 with PPH due to collagen disease. RV parameters were assessed by echocardiography and Radionuclide ventriculography. Pulmonary function and clinical profile were assessed by 6 min walk test and NYHA class. The patients were followed-up during 2 years for cardiac death and cardiac deterioration.

RESULTS

Mean age was 51 +/- 15 years, 22 (78%) women. NYHA class1 in 2 pts, class 2 in 17, class 3 in 8 and class 4 in 2 pts. Pulmonary function (DLCO) was low in 25 (86%) pts, mean 22 +/- 48%. Six minutes walk distance was 358 +/- 132 m, RVEF was 34 +/- 11% (range 16-51%). Among RV variables, RVEF, RA area and TR were independently correlated to 6 min walk. Within follow up of 2 years, there were 10 patients with adverse outcome (4 deaths and 6 deteriorated to NYHA class 3 and 4). Among all clinical and noninvasive variables, RVEF only was correlated to adverse outcome.

CONCLUSION

The noninvasive tests of RVEF, RA size and TR were closely correlated to exercise tolerance. However, among the various clinical, functional and RV variables, RVEF was the only variable correlated with adverse outcome in pts with PPH.

Tissue Doppler imaging in patients with advanced heart failure: relation to functional class and prognosis

BACKGROUND

Tissue Doppler imaging (TDI) provides rapid assessment of systolic and diastolic myocardial function. However, the added value of TDI to standard Doppler echocardiographic measurements in predicting symptoms and outcome of advanced heart failure remains unknown.

METHODS

The study cohort comprised 45 patients with congestive heart failure, defined as New York Heart Association functional class III and IV, who were referred to our department for evaluation for heart transplantation. Twenty healthy subjects were the controls. Conventional echo Doppler was used to assess left ventricular (LV) ejection fraction, peak velocities of transmitral early and late diastolic LV filling, the ratio of transmitral early to late LV filling velocity, and E-deceleration time. TDI measurements recorded at the mitral annulus included systolic velocity, early and late diastolic velocities, and the ratio of early to late diastolic velocity. The ratio of transmitral early LV filling velocity to early diastolic TDI velocity of the mitral annulus (E/E') was calculated. All patients were followed for cardiac-related death and hospitalization for heart failure.

RESULTS

Patients with functional class IV had a significantly higher E/E' ratio than did patients with functional class III (12.9 +/- 2.8 vs 8.3 +/- 1.7, p < 0.001) and the controls (5.4 +/- 1.3, p < 0.001). Except for transmitral late filling velocity, all conventional echo Doppler parameters and TDI variables significantly correlated with functional class. On multivariate stepwise analysis, however, the E/E' ratio was the only independent predictor of functional class (p = 0.003). E/E' also correlated with cardiac mortality and hospitalization.

CONCLUSION

Conventional Doppler indices and TDI parameters correlated with functional class in patients with advanced heart failure. The E/E' ratio, which probably reflects high LV end-diastolic pressure, was the best measure for differentiating patients with functional class III and IV, and it also correlated with cardiac mortality and hospitalization for worsening heart failure, thereby providing additional value to standard echocardiographic measures.

Impaired tissue Doppler diastolic function in patients with coronary artery disease: relationship to endothelial damage/dysfunction and platelet activation

BACKGROUND

Pulsed tissue Doppler imaging (TDI) allows direct measurement of systolic and diastolic function of the left ventricle. In patients with coronary artery disease (CAD), myocardial ischemia-related impaired diastolic function may be linked to systemic endothelial damage/dysfunction and increased thrombogenesis. We hypothesized relationships between TDI-defined diastolic dysfunction and plasma von Willebrand factor (vWf, marking endothelial damage/dysfunction), soluble P-selectin (sP-sel, reflecting platelet activation), fibrin D dimer (an index of fibrin turnover and thrombogenesis), fibrinogen, and plasma viscosity (PV) in CAD.

METHODS

Conventional 2-dimensional Doppler echocardiography and TDI were performed in 75 stable CAD patients (55 men, 59 +/- 11 years) and 40 age- and sex-matched healthy controls. Peak systolic (Sm), peak early (Em), and late (Am) diastolic mitral annular velocities measured at 4 sites (septal, lateral, inferior, and anterior) were averaged as global systolic and diastolic left ventricular function, respectively. The mean TDI velocities were dichotomized into low and high (below/above median) groups. Plasma vWf, sP-sel, D dimer (enzyme-linked immunosorbent assay), fibrinogen (modified Clauss), and PV levels were measured.

RESULTS

CAD patients had significantly lower Sm, Em, Em/Am ratio, and a higher ratio of early transmitral flow E-velocity over Em (E/Em) when compared with controls (all P < .05). On multivariate analysis, adjusted for age, ejection fraction, and clinical variables, the differences in the group means of vWf, sP-sel, and fibrinogen remained significantly different between the low and high TDI indexes. D-dimer levels were unrelated to any TDI indexes. None of the transmitral flow indexes were independently related to the research indexes.

CONCLUSIONS

In patients with CAD, diastolic dysfunction was closely associated with increased platelet activation and endothelial damage/dysfunction independent of systolic function. TDI-derived indexes are more sensitively related to plasma hemostatic markers than transmitral indexes in middle-aged patients with CAD.

Evaluation of cardiac function by tissue Doppler echocardiography: hemodynamic determinants and clinical application

A total of 32 patients without regional wall motion abnormality of the left ventricle underwent sequential tissue Doppler echocardiography and cardiac catheterization. Peak velocities of systolic (Sa), early diastolic (Ea), and late diastolic (Aa) motion of the mitral annulus were measured. Normal references for Sa, Ea and Aa were obtained from 138 volunteers. Indices of left ventricular (LV) systolic and diastolic function were evaluated using high-fidelity LV pressure and volume signals. By multivariate analysis, Sa, Ea and As were significantly and independently related to the maximum of the first derivative of pressure over time (dP/dt(max)), LV relaxation time constant (tau), and LV ejection fraction (EF), respectively. Using the fifth percentiles of the age-stratified normal references as cut-offs, low Sa, low Ea and low Aa identified declined dP/dt(max), prolonged tau and reduced EF, respectively, with good sensitivities and specificities. In conclusion, mitral annulus velocities by tissue Doppler echocardiography can be used to identify patients with declined dP/dt(max), prolonged tau and reduced EF.

The role of apically directed intraventricular isovolumic relaxation flow in speeding early diastolic left ventricular filling

Left ventricular (LV) systolic performance has been acknowledged to have a close relation to LV early diastolic filling and LV relaxation. However, the mechanism showing how good LV systolic function enhances the LV early diastolic filling has not been fully elucidated from the viewpoint of intraventricular flow dynamics. Thus, we investigated this issue in 82 patients with suggested coronary artery disease who underwent cardiac catheterization. Apically directed intraventricular isovolumic relaxation flow (IRF) and the propagation velocity of early diastolic filling flow were measured using pulsed and color Doppler echocardiography. LV ejection fraction and LV relaxation time constant tau were obtained in cardiac catheterization. As we were not able to measure the IRF velocity less than 14 cm/s that was limited by a Doppler low-cut filter, we analyzed the data collected from 78 patients with measurable IRF velocity. The IRF velocity significantly correlated with LV ejection fraction (r = 0.74, P <.001) and with LV relaxation time constant tau (r = -0.31, P <.01). The propagation velocity of early diastolic filling flow significantly correlated with the IRF velocity (r = 0.73, P <.001) and also significantly correlated with LV ejection fraction (r = 0.70, P <.001). Good LV systolic performance augments LV early diastolic filling directly, mediated by IRF. A faster IRF velocity may play a role in delivering good LV systolic performance to LV early diastolic filling.

Left Ventricular Long-Axis Function Is Reduced in Patients with Rheumatic Mitral Stenosis

Left ventricular long-axis function evaluated by M-mode or tissue Doppler echocardiography has been shown to be useful indexes of left ventricular systolic function; however it has not been evaluated in patients with mitral stenosis. We examined the left ventricular long-axis function of the patients with pure mitral stenosis and normal global systolic function as assessed by fractional shortening of the left ventricle (LV). Fifty-two patients with pure mitral stenosis and twenty-two healthy controls were evaluated by echocardiography. Although there was no statistically significant difference in global systolic function, M-mode derived systolic motion of the septal side and (12 +/- 3 vs 14.4 +/- 1.5 mm, P = 0.016) the lateral side of mitral annulus (13.2 +/- 3 vs 16.8 +/- 2 mm, P = 0.001) were both significantly lower in the patients with mitral stenosis than control subjects. Similarly tissue Doppler systolic velocity of the septal annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.03) and lateral mitral annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.003) were also significantly lower in patients with mitral stenosis than in controls. There was a statistically significant correlation between septal annular motion and annular velocity (r = 0.643, P = 0.002). Septal annular motion and annular velocity were also correlated with left atrial ejection fraction (r = 0.338, P = 0.005 and r = 0.676, P = 0.001, respectively). Thus, patients with mitral stenosis had significantly impaired long-axis function evaluated by M-mode or tissue Doppler echocardiography despite normal global systolic function.

Spectral pulsed tissue Doppler imaging in diastole: a tool to increase our insight in and assessment of diastolic relaxation of the left ventricle

BACKGROUND

Conventional Doppler echocardiography offers an indirect assessment of left ventricular (LV) diastolic function, hampered by preload dependency. Tissue Doppler imaging (TDI) is a tool to study diastolic function in a more direct and less preload-dependent manner.

METHODS

The Medline database has been searched for literature on TDI for the analysis of diastolic function. A secondary search reviewed the relevant references related to TDI or diastolic function in general.

RESULTS

TDI measures myocardial velocities with a high temporal and velocity resolution but lacks spatial information. In particular, the velocity of early diastolic wall motion (E(m)) and its timing are promising indices of local myocardial relaxation. E(m) at the mitral annulus offers fair estimates of ventricular relaxation, relatively independent of preload and systolic function. Combined with early transmitral flow velocity (E), detection of pseudo-normalized filling patterns and estimation of filling pressures are enhanced by E/E(m).

CONCLUSION

TDI has an emerging role in the study and assessment of diastolic function. However, TDI-derived information needs to be integrated with other echocardiographic data because single diagnostic accuracy remains unsatisfactory.

New parameters in identification of right ventricular myocardial infarction and proximal right coronary artery lesion

OBJECTIVE

The diagnosis of right ventricular myocardial infarction (RVMI) accompanied by acute inferior myocardial infarction (MI) is still a problem that we encounter. This study was designed to find out the usefulness both of peak myocardial systolic velocity (Sm) and of the myocardial performance index (MPI) of the right ventricle measured by pulsed-wave tissue Doppler imaging (TDI) in assessing right ventricular function.

METHODS

Sixty patients who experienced a first acute inferior MI (mean [+/- SD] age, 57 +/- 9 years) were prospectively assessed. An ST-segment elevation of >or= 0.1 mV in V(4)-V(6)R lead derivations was defined as an RVMI. From the echocardiographic apical four-chamber view, the Sm, the peak early diastolic velocity, peak late diastolic velocity, the ejection time, the isovolumetric relaxation time, and the contraction time of the right ventricle were recorded at the level of the tricuspid annulus by using TDI. Then, the MPI was calculated. The patients were classified into the following three groups, according to the localization of the infarct-related artery (IRA) detected using coronary angiography: group I, proximal right coronary artery; group II, distal right coronary artery; and group III, circumflex coronary artery.

RESULTS

RVMIs were detected in sixteen patients, and the IRA in 27 patients was the proximal right coronary artery. The right ventricular Sm was observed to be significantly low in patients with RVMIs and those in group I compared to those without RVMIs and those in groups II and III (10.9 +/- 1.3 vs 14.3 +/- 3.2 cm/s, respectively [p < 0.001]; 11.5 +/- 2.5 vs 15.1 +/- 3 cm/s, respectively; and 14.9 +/- 2.6 cm/s, respectively [p < 0.001]). In the diagnosis of RVMI, the values for sensitivity, specificity, negative predictive value, and positive predictive value of Sm < 12 cm/s were 81%, 82%, 92%, and 62% respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 63%, 88%, 74%, and 81%, respectively. The MPI was high in the same patient groups (0.83 +/- 0.12 vs 0.57 +/- 0.11 in those patients without RVMI, respectively, [p < 0.001]; 0.74 +/- 0.13 vs 0.56 +/- 0.15 in group II and 0.54 +/- 0.07 in group III, respectively [p < 0.001]). The sensitivity, specificity, negative predictive value, and positive predictive value of an MPI of > 0.70 in the diagnosis of RVMI were calculated as 94%, 80%, 97%, and 63%, respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 78%, 91%, 83%, and 88% respectively.

CONCLUSIONS

An Sm <12 cm/s and an MPI > 0.70 obtained by TDI may define RVMI concomitant with acute inferior MI, and the IRA.

Peak early diastolic mitral annulus velocity by tissue Doppler imaging adds independent and incremental prognostic value

OBJECTIVES

The aim of this study was to ascertain if left ventricular mitral annulus velocities measured by tissue Doppler imaging (TDI) are more powerful predictors of outcome compared with clinical data and standard Doppler-echocardiographic parameters.

BACKGROUND

Tissue Doppler imaging of basal or mitral annulus velocities provides rapid assessment of ventricular long axis function. But it is not known if TDI-derived velocities in systole and diastole add incremental value and are superior to the standard Doppler-echocardiographic measurements as a predictor of outcome.

METHODS

The study population consisted of 518 subjects, 353 with cardiac disease and 165 normal subjects who had full Doppler two-dimensional-echocardiographic studies with measurement of mitral inflow velocities in early and late diastole, E-wave deceleration time (DT), peak systolic mitral annular velocity (Sm) early and late diastolic mitral annular velocity (Em and Am) by TDI, early diastolic flow propagation velocity, and standard chamber dimensions. All subjects were followed up for two years. The end point was cardiac death.

RESULTS

Tissue Doppler imaging mitral annulus systolic and diastolic velocities were all significantly lower in the non-survivors (all p < 0.05) as was DT (p = 0.024). In the Cox model the best predictors of mortality were Em, Sm, Am, left ventricular ejection fraction, left ventricular mass, and left atrial diameter in systole (LADs). By backward stepwise analysis Em and LADs were the strongest predictors. After forcing the TDI measurements into the covariate model with clinical and mitral DT <0.16 s, Em provided significant incremental value for predicting cardiac mortality (p = 0.004).

CONCLUSIONS

Mitral annulus velocity measured by TDI in early diastole gives incremental predictive power for cardiac mortality compared to clinical data and standard echocardiographic measurements. This easily available measurement adds significant value in the clinical management of cardiac patients.

Analysis of the myocardial velocities in patients with mitral stenosis

BACKGROUND

Pure mitral stenosis (MS) affects left-ventricular performance as a result of myocardial and functional factors. We planned this study to evaluate the effect of MS on right- and left-ventricular functions using Doppler tissue imaging (DTI).

METHODS

A total of 46 patients with an established diagnosis of MS (mean age: 41 +/- 11 years), and 40 age-matched healthy individuals (mean age: 40 +/- 9 years) were included in this study. Echocardiography equipped with DTI function was performed on each participant. The mitral valve area was measured. Myocardial velocities were recorded at 4 different sites (septum, lateral, anterior, and inferior) of the left ventricle, and the right-ventricular free wall annulus by DTI. The positive systolic velocity when the mitral and tricuspid ring moved toward the cardiac apex, and 2 negative diastolic velocities when the mitral annulus moved toward the base away from the apex (1 during the early phase of diastole and another in the late phase of diastole [A(m)]) were measured. The early diastolic velocity/A(m) ratio was calculated for each wall. The mean of systolic and diastolic myocardial velocities of the left ventricle was calculated. Patients with pure MS were compared with healthy participants, and the relationship of DTI variables with mitral valve area was evaluated.

RESULTS

The myocardial velocities of the left ventricle indicating left-ventricular function were found to be significantly lower in patients with pure MS. Right-ventricular annulus velocities, on the other hand, were similar in both groups. A significant positive correlation could be established between mitral valve area and mean positive systolic velocity, A(m) of the left ventricle, and right-ventricular A(m) (r = 0.50, P <.001; r = 0.48, P =.001; r = 0.45, P =.002, respectively), whereas a significant negative correlation (r = -0.42, P =.004) was established for right-ventricular early diastolic velocity/A(m) ratio.

CONCLUSION

This first study where pure MS was evaluated by DTI shows that MS affects left-ventricular performance on long axis. The results indicate that the decrease in left-ventricular performance is caused by both functional and myocardial factors.

Tissue Doppler imaging for the assessment of left ventricular systolic and diastolic functions

Doppler tissue imaging is a technique that allows recording of the low Doppler shift frequencies of high energy generated by the ventricular walls motion that are purposely filtered out in standard Doppler blood flow studies. Doppler tissue imaging can be performed with the use of pulsed Doppler, color two-dimensional Doppler, and color M-mode Doppler. Pulsed Doppler tissue imaging offers a high temporal resolution and therefore can be appropriately used for analysis of temporal relation between myocardium systolic and diastolic velocity waves. Color two-dimensional Doppler provides a good spatial resolution that permits differentiation of the velocity profiles between subendocardial and subepicardial layers but is limited by its poor temporal resolution. M-mode color-coded tissue imaging is characterized by a high spatiotemporal resolution, but sampling is only performed on a single line. Both two-dimensional and M-mode color-coded tissue imaging require specific modification of the current ultrasound machines. The present article reviews how Doppler tissue imaging may contribute to the noninvasive assessment of systolic and diastolic myocardial functions.

Alternative Echocardiographic Methods to Assess Left Ventricular Diastolic Function

The standard noninvasive method to assess left ventricular diastolic function has been pulsed Doppler echocardiographic recordings of mitral inflow early diastolic (E) and atrial (A) filling velocities and the ratio of E to A, in combination with isovolumic relaxation and deceleration times. Pulmonary venous inflow velocities (systolic, diastolic, and atrial reversal) are used to assess left atrial and left ventricular end-diastolic pressures. These measurements are influenced by changes in preload, including left ventricular end-diastolic pressure, left atrial or pulmonary capillary wedge pressure, and left ventricular volumes. Newer methods such as tissue Doppler imaging (TDI) of the mitral annulus and color M-mode recording of left ventricular diastolic flow propagation (FP) have now evolved as additional techniques for detecting abnormalities in left ventricular diastolic function that can complement the standard pulsed Doppler echocardiography methods. Both TDI and color M-mode flow FP appear to offer distinct advantages as relatively load-independent measures of diastolic function. TDI can be used for measurement of regional diastolic myocardial velocities at the mitral annulus, and it is particularly useful in identifying abnormalities of left ventricular diastolic relaxation or estimation of left ventricular filling pressures. Color M-mode FP can be used for quantification of abnormalities of left ventricular relaxation and diastolic filling characteristics of the left ventricle.

Quantification of left ventricular diastolic pressure-volume relations during routine cardiac catheterization by two-dimensional digital echo quantification and left ventricular micromanometer

BACKGROUND

Currently there is no simple clinical method for quantifying the left ventricular (LV) diastolic pressure-volume relation. Echocardiographic-automated endocardial border detection, however, may be combined with LV micromanometer to construct LV pressure-volume loops. We investigated the feasibility of on-line display and sampling of LV pressure-volume loops by such an approach. For this purpose we used a new echocardiographic digital echo quantification (DEQ) method in combination with LV pressures on-line and in real-time.

METHODS

Eighteen patients were screened by conventional echocardiography and DEQ. Ten of the patients with high quality images were included in the study. Left ventricular pressures and volumes were recorded simultaneously and were displayed on-line as pressure-volume loops. Changes in LV volume were induced by intravenous saline. Left ventricular chamber compliance was estimated as change in volume divided by change in pressure from minimum diastolic pressure to end-diastolic pressure (average LV chamber compliance).

RESULTS

Left ventricular pressure-volume loops were displayed on-line during the examination. When compared with the Simpson's method, DEQ underestimated end-diastolic volume (EDV) by 35% and overestimated end-systolic volume (ESV) by 14%. Beat-to-beat variability for ESV and EDV were 7.4% +/- 0.8% and 7.2% +/- 0.7 %, respectively. Volume loading increased LV end-diastolic pressure (LVEDP) from 14.0 +/- 1.6 to 24.7 +/- 2.0 mm Hg (P <.05) and EDV from 79 +/- 10 to 85 +/- 11 mL (NS), and decreased LV chamber compliance from 4.0 +/- 0.7 to 2.0 +/- 0.3 mL/mm Hg (P <.05).

CONCLUSION

The current study demonstrates that LV pressure-volume loops can be displayed and evaluated in real-time during routine cardiac catheterization. This may represent a clinically useful method for identifying patients with reduced chamber compliance. The underestimation of the volumes by DEQ compared with the Simpson's method suggests that further refinements should be performed to improve the endocardial border detection algorithm.

Tissue Doppler imaging: a useful echocardiographic method for the cardiac sonographer to assess systolic and diastolic ventricular function

Tissue Doppler imaging (TDI) has evolved to become a useful noninvasive method that can complement other echocardiographic techniques in the assessment of left ventricular myocardial velocities in a variety of clinical conditions. Color 2-dimensional and color M-mode TDI are used for quantification of systolic myocardial velocities during myocardial ischemia at rest and with pharmacologic stress testing. Spectral pulsed TDI can provide measurements of regional systolic and diastolic myocardial velocities, and it is particularly useful in the identification of abnormalities of left ventricular diastolic relaxation. This review summarizes the clinical applications of TDI to promote understanding of its utility in the evaluation of left ventricular myocardial function.

Striking effect of left ventricular systolic performance on propagation velocity of left ventricular early diastolic filling flow

Propagation velocity of left ventricular (LV) early diastolic filling flow (PVE) has been acknowledged as a useful parameter for LV early diastolic performance; however, the effect of LV systolic performance on PVE is not fully understood. Thus the purpose of this study was to investigate such an effect. Propagation of LV early diastolic filling flow was visualized by M-mode color Doppler imaging, and the slopes of the peak velocity tracings were measured as PVE in 150 patients who underwent coronary angiography. In cardiac catheterization, mean pulmonary capillary wedge pressure, time constant tau of LV pressure decay, LV end-systolic volume index, and LV ejection fraction were obtained. In univariate regression analysis, PVE significantly correlated with LV end-systolic volume index (r = -0.68, P <.001), LV ejection fraction (r = 0.66, P <.001), and time constant tau (r = -0.52, P <.001). In multivariate regression analysis, PVE was regressed by the LV end-systolic volume index, tau, and mean pulmonary capillary wedge pressure. The contribution of each parameter to the variance of the PVE was 46%, 3%, and 2%, respectively. A break-point linear regression analysis showed that the relation between the LV end-systolic volume index and PVE was much better characterized by a broken line than a straight line. The broken line had a steeper slope in patients with LV end-systolic volume index < or =41 mL/m(2) than in those with >41 mL/m(2). These findings suggest that PVE is determined mainly by LV systolic performance and partly by both LV relaxation and LV filling pressure. Left ventricular systolic performance may play a key role in generating a much faster PVE, especially in patients with relatively better LV systolic performance.

Age-dependent changes in regional diastolic function evaluated by color Doppler myocardial imaging: a comparison with pulsed Doppler indexes of global function

The goals of this study were to evaluate possible normal age-related changes in regional myocardial relaxation as detected by color Doppler myocardial imaging (CDMI) velocities and to compare the extent of any such changes with age-induced changes in global diastolic function. In 80 healthy subjects (aged 21 to 72 years, equally subdivided by decades) the mitral flow velocities in early diastole (E) and atrial contraction (A) were recorded as were the velocities of left ventricular (LV) motion of early (EDV) and late diastole (LDV) in the 16 standard LV segments, and their ratios were calculated. In healthy persons younger than 40 years, all segments showed an EDV/LDV ratio > 1, whereas in healthy persons aged 40 years or older the mean EDV of all segments decreased, and the mean LDV increased, resulting in a significant decrease of the mean EDV/LDV ratio with age. Values of EDV/LDV ratios were higher than E/A ratios (P <.0001), but their changes with age correlated well with each other (r = 0.805). With increasing age, an EDV/LDV ratio <1 was observed more often in basal segments (P <.001, compared with mid and apical segments) and less often in segments of anteroseptal and posterior walls viewed from the parasternal window. The presence of >50% segments with an EDV/LDV ratio <1 was associated with an E/A ratio <1. Regional diastolic function indexes as evaluated by CDMI changed with increasing age in a heterogeneous way and influenced global diastolic function parameters.

Long axis electromechanics during dobutamine stress in patients with coronary artery disease and left ventricular dysfunction

OBJECTIVE

To dissociate the effect of inotropy from activation change during dobutamine stress on left ventricular long axis function in patients with coronary artery disease (CAD).

METHODS

25 patients with CAD and normal left ventricular cavity size and 30 with cavity dilatation-18 with normal activation (DCM-NA) and 12 with left bundle branch block (DCM-LBBB)-were compared with 20 controls. 12 lead ECG and septal long axis echograms were assessed at rest and peak dobutamine stress. Amplitude, shortening and lengthening velocities, postejection shortening, Q wave to onset of shortening (Q-OS), and A2 to onset of lengthening (A2-OL) were measured. Inotropy was evaluated from peak aortic acceleration.

RESULTS

In controls, amplitude, shortening and lengthening velocities, and peak aortic acceleration increased with stress; QRS, Q-OS, and A2-OL shortened (all p < 0.001); and contraction remained coordinate. In the group of patients with CAD and normal left ventricular cavity size, shortening velocity and peak aortic acceleration increased with stress (p < 0.005). However, amplitude and lengthening velocity did not change, QRS, Q-OS, and A2-OL lengthened (p < 0.01), and incoordination appeared. Results were similar in the group with DCM-NA. In the DCM-LBBB group, shortening velocity and peak aortic acceleration increased modestly with stress (p < 0.01) but amplitude, lengthening velocity, QRS, Q-OS, A2-OL, and incoordination remained unchanged. Overall, change in shortening velocity correlated with that in peak aortic acceleration (r(2) = 0.71), in amplitude with that in lengthening velocity (r(2) = 0.74), and in QRS with both Q-OS (r(2) = 0.69) and A2-OL (r(2) = 0.63).

CONCLUSION

The normal long axis response to dobutamine reflects both inotropy and rapid activation. In CAD, inotropy is preserved with development of ischaemia but the normal increase in amplitude is lost and prolonged activation delays the time course of shortening, causing pronounced incoordination. Overall, shortening rate uniformly reflects inotropy while lengthening rate depends mainly on systolic amplitude rather than primary diastolic involvement, even with overt ischaemia.