Assessment of left ventricular function using mitral annular velocities in patients with congestive heart failure with or without the presence of significant mitral regurgitation

Clinical implication of LAVI over A' ratio in patients with acute coronary syndrome

Purpose

The ratio of the left atrial volume index (LAVI) and late diastolic mitral annular velocity (A') is a useful echocardiographic index for identifying advanced left ventricular (LV) diastolic dysfunction in patients with dyspnoea. We investigated the clinical implications and prognostic value of the aforementioned ratio (LAVI/A') in patients with ST elevation (STE) or non-STE (NSTE) acute coronary syndrome (ACS).

Methods

We studied 212 patients with ACS. All patients underwent electrocardiography, echocardiography and measurement of plasma B-type natriuretic peptide (BNP) level on admission. The study endpoints were hospitalisation and mortality because of heart failure (HF).

Results

There was a significant, moderate positive correlation between LAVI/A' and natural logarithm (Ln) BNP level among the participants (r=0.48, p<0.0001). During a mean follow-up of 17 months, eight patients died and nine patients were hospitalised because of HF. The receiver operating characteristics curve indicated that LAVI/A'≥3.0 predicted these events (log-rank, p=0.0021). A significant and moderate positive correlation existed between LAVI/A' and Ln BNP level in the NSTE-ACS group (n=128; r=0.58, p<0.0001). However, the correlation between LAVI/A' and Ln BNP level was weaker in the STE-ACS group (n=84; r=0.33, p=0.0017).

Conclusion

LAVI/A' was related to plasma BNP levels in patients with ACS, particularly in those with NSTE-ACS. This index was useful for predicting cardiac events in patients with ACS.

Imaging 4D morphology and dynamics of mitral annulus in humans using cardiac cine MR feature tracking

Feature tracking in cine cardiac magnetic resonance (CMR) is a quantitative technique to assess heart structure and function. We investigated 4-dimensional (4D) dynamics and morphology of the mitral annulus (MA) using a novel tracking system based on radially rotational long-axis cine CMR series. A total of 30 normal controls and patients with mitral regurgitation were enrolled. The spatiotemporal changes of the MA were characterized by an in-house developed program. Dynamic and morphological parameters extracted from all 18 radial slices were used as references and were compared with those from subsequently generated sub-datasets with different degrees of sparsity. An excellent agreement was found among all datasets including routine 2-, 3- and 4-chamber views for MA dynamics such as peak systolic velocity (Sm) and mitral annular plane systolic excursion (MAPSE). MA morphology for size and shape was addressed adequately by as few as 6 radial slices, but poorly by only three routine views. Patients with regurgitation showed significantly reduced mitral dynamics and mild annular deformation, which was consistent between three routine views and 18 reference slices. In conclusion, feature tracking cine CMR provided a comprehensive and distinctive profile for 4D MA dynamics and morphology, which may help in studying different cardiac diseases.

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.

Effect of food intake on left and right ventricular systolic tissue Doppler measurements

Systolic tissue Doppler measurements (s') have been used to measure the velocity in myocardial motion and are a valuable tool for evaluating the systolic function of the left and right ventricles. Digestion of food is known to significantly alter hemodynamics and may therefore affect s'. The effect of food intake on s' parameters has not yet been studied. We assessed whether s' is affected by food intake. Nineteen healthy subjects aged 26·2 ± 4·2 years were investigated. s' was measured with pulsed tissue Doppler imaging in the right and left ventricles before the subjects ate a standardized meal and also 30 and 110 min after the meal. Three measurements were taken in each projection, and a mean value was calculated for each. s' increased significantly (P<0·05) from fasting to 30 min after food intake in every measured site except in the left inferolateral wall (P = 0·15, NS). Several, but not all, variables returned to base value 110 min after food intake. This study shows that food intake affects the tissue Doppler variables used to evaluate systolic heart function. Further studies are needed in older healthy subjects and older subjects with various cardiovascular diseases.

Ratio of early diastolic tricuspid inflow to tricuspid lateral annulus velocity reflects pulmonary regurgitation severity but not right ventricular diastolic function in children with repaired Tetralogy of Fallot

The current study assessed relationships between the ratio of early diastolic tricuspid inflow to tricuspid lateral annular velocity (tricuspid E/e') and right ventricular (RV) function in children after tetralogy of Fallot (TOF) repair. The RV function of 25 asymptomatic children with surgically repaired TOF (age 3.3 ± 2.0 years) was assessed by echocardiography and cardiac catheterization. Right ventricular end-diastolic pressure and volume (RVEDP and RVEDV), systolic pressure, and ejection fraction, as well as mean pulmonary arterial pressure, mean right atrial pressure (RAP), and the severity of both pulmonary regurgitation (PR) and tricuspid regurgitation (TR) were assessed in terms of the contribution to tricuspid E/e'. Univariate analysis discovered a relationship between tricuspid E/e' and RVEDV (R(2) = 0172), pressure half-time of PR (PR-PHT) (R(2) = 0.173), and TR grade (R(2) = 0.145) (p < 0.01 for each). After multivariate adjustment, PR-PHT was significantly associated with tricuspid E/e' (β = 0.210; p < 0.001). Tricuspid E/e' was not significantly associated with RVEDP or RAP. In conclusion, tricuspid E/e' does not indicate RV diastolic function but reflects the severity of PR in asymptomatic children after TOF repair.

Usefulness of mitral annular systolic velocity in the detection of left ventricular systolic dysfunction: comparison with three dimensional echocardiographic data

BACKGROUND

Although the modified Simpson's method is widely used for the assessment of left ventricular ejection fraction (LVEF), it has limitations including relatively high inter- and intra-observer variability and time consuming nature. We want to evaluate whether assessing mitral annular systolic velocity (S' velocity) by tissue Doppler imaging (TDI) can be used to evaluate LV systolic function with comparing LVEF by three dimensional echocardiography (3DE).

METHODS

We examined 3DE and TDI studies of patients between January and August 2008. 3DE LVEF was measured by offline commercial computer software EchoPac PC(R) (GE, Andover, MA, USA). S' velocity was obtained from the medial side with apical four chamber view by pulsed-wave Doppler with TDI.

RESULTS

We included 125 patients (78 males (62.4%), mean age: 57.5+/-13.0 years). The mean S' velocity was 7.7+/-1.9 cm/s and the mean LVEF was 57.2+/-10.4%. The S' velocity measured by TDI showed a linear correlation with LVEF measured by 3DE (r=0.688, p<0.001). Study patients were divided into two groups according to the presence of LV systolic dysfunction: Group I (normal LVEF), n=102 and Group II (LVEF <50%), n=23. For prediction of significant LV systolic dysfunction by the receiver operating characteristic curve according to S' velocity, the optimal cutoff value was 6.8 cm/s. At this cutoff value, the sensitivity and specificity were 94.1% and 87%, respectively.

CONCLUSION

In this study, S' velocity measured by TDI showed a significant correlation with three dimensional LVEF and can be used to detect patients with LV systolic dysfunction.

Reproducibility in echocardiographic assessment of the left ventricular global and regional function, the HUNT study

AIMS

The study aimed to compare the inter-observer reproducibility of new and traditional measurements of the left ventricular (LV) global and regional function.

METHODS AND RESULTS

Two experienced echocardiographers performed 20 complete echo/Doppler examinations and 50 analyses on ten healthy subjects. All recordings were analysed for systolic and diastolic conventional and deformation measurements by both echocardiographers. Inter-observer mean error (absolute difference divided by the mean) was 4% and lowest (P = 0.001) for systolic M-mode annulus excursion. Mean error for the regional deformation indices was significantly higher than for all the global measurements (all P < 0.001). Mean error for analyses of the same recording was 34% (P = 0.002) lower for global systolic indices and 44% (P < 0.001) lower for global diastolic indices than inter-observer mean error for analyses made in separate recordings.

CONCLUSION

Systolic M-mode annulus excursion showed better inter-observer reproducibility than other traditional and newer measurements of LV systolic and diastolic function. Repeated analyses of the same recordings underestimate the more clinically relevant inter-observer reproducibility by approximately 40% for most measurements of LV function.

Left ventricular ejection time on echocardiography predicts long-term mortality in light chain amyloidosis

OBJECTIVE

Light chain amyloidosis (AL) is associated with high mortality. The aim was to identify echocardiographic parameters that predict AL long-term mortality.

METHODS

Forty-two subjects with biopsy-proven AL (43% were female; aged 61 +/- 12 years) underwent echocardiography and were followed 29 +/- 16 months (median 29.4 months). Standard echocardiographic and clinical parameters and heart failure (HF) class were tested using univariate/multivariable Cox proportional hazard regression analyses to identify markers of mortality.

RESULTS

Twenty-three subjects died, with a 1-year mortality of 44%. Univariate predictors of mortality were HF class (P < .001), left ventricular systolic ejection time (ET) (P = .002), alkaline phosphatase (P < .001), and aspartate and alanine aminotransferase (P = .003 each). On multivariable analysis, only HF class (hazard ratio [HR] 4.86; 95% confidence interval [CI], 1.58-14.9; P = .006), ET (10 ms increase; HR 0.87; CI, 0.78-0.97; P = .01), and alkaline phosphatase (10 U/L increase; HR 1.04; CI, 1.01-1.06; P = .01) were prognostic. ET <or= 240 ms had a sensitivity of 61% and a specificity of 90% in predicting 1-year mortality and a sensitivity of 73% and a specificity of 90% in predicting 1-year cardiac mortality.

CONCLUSION

AL amyloidosis was associated with high long-term mortality. Among echocardiographic and clinical parameters, only ET and alkaline phosphatase had incremental value to HF class in predicting mortality. This may be useful to identify high-risk patients.

The syndrome of cardiac failure in adults with congenitally corrected transposition

OBJECTIVES

To assess neurohormonal activation of cardiac failure in adults with congenitally corrected transposition, and to determine the most sensitive marker for recognition of the cardiac failure.

BACKGROUND

The onset of morphologically right ventricular dysfunction is unpredictable in patients with congenitally corrected transposition, the combination of discordant atrioventricular and ventriculo-arterial connections, and its markers are unknown.

METHODS

We measured amino terminal pro brain natriuretic peptide in 19 patients, aged 35 plus or minus 13.1 years, and in 19 control subjects. Morhologically right ventricular function was assessed by echocardiography, including tissue Doppler echocardiography and magnetic resonance imaging or multislice computed tomography.

RESULTS

The patients showed a highly significant increase in the levels of amino terminal pro brain natriuretic peptide, the levels being significantly elevated even in asymptomatic patients. Left atrial dimensions were larger in patients, and significantly lower tissue Doppler echocardiographic velocities were measured at the lateral site of the tricuspid annulus and at the basal segment of the interventricular septum. The ejection fraction of the morphologically right ventricle correlated significantly with the levels of brain natriuretic peptide, and with left atrial dimensions.

CONCLUSIONS

Neurohormonal activation is present in patients with congenitally corrected transposition even when they are asymptomatic. It is correlated with left atrial dimensions and tissue Doppler echocardiographic parameters. Levels of brain natriuretic peptide, and peak tricuspid early diastolic annular velocity, are the earliest and most sensitive markers of morphologically right ventricular dysfunction.

Impact of myocardial geometry on left ventricular performance in healthy black and white young adults

Racial differences in left ventricular (LV) structure are suggested by clinical and experimental studies. This study evaluates if racial differences in LV performance exist comparing black to white young males, by tissue Doppler echocardiography and myocardial performance index (MPI). We examined 40 healthy males, 20 blacks (mean age 27.6 +/- 4.4 years) and 20 whites (mean age 26.5 +/- 6.7 years). All subjects underwent conventional echocardiography, tissue Doppler echocardiography, and MPI assessment. No differences were found in LV diameters, volumes, mass, and hemodynamic measurements. Septal and posterior wall thicknesses were significantly increased in black subjects as well as the relative wall thickness. Systolic and diastolic functions estimated by conventional parameters were superimposable in the two groups. In black subjects, a significant increase of septal S-wave, peak velocity, and time-velocity integral were found. MPI was significantly higher in black compared to white subjects (0.46 +/- 0.05 vs 0.40 +/- 0.06, P < 0.002). A significant correlation between MPI and relative wall thickness (r = 0.54) was demonstrated. Besides, MPI correlated with S(pv) (r = 0.55) and S(tvi) (r = 0.38) at the septal site. In conclusion our data show a higher MPI in black subjects that seems to be geometry-dependent. Correlations between MPI and tissue Doppler echocardiography systolic indexes were found. Our findings suggest that racial differences in LV performance exist, especially, in the systolic function, even in the absence of other conventional echocardiographic changes.

Detection of left ventricular dysfunction by Doppler tissue imaging in patients with complete recovery of visual wall motion abnormalities 6 months after a first ST-elevation myocardial infarction

AIMS

The aim of this study was to assess left ventricular (LV) systolic and diastolic function, using Doppler tissue imaging (DTI), in patients with complete recovery of visual wall motion abnormalities six months after a first ST-elevation myocardial infarction (STEMI).

METHODS

Out of 90 patients presenting with a STEMI, 68 patients without a history of heart disease were examined by echocardiography before discharge and after 6 months. The patients were compared to 41 age matched healthy subjects (HS). LV function was assessed by visual wall motion and mitral annular velocities using pulsed wave DTI.

RESULTS

Sixty-eight patients had visual wall motion abnormalities at baseline. Of these, 19 patients showed complete recovery of wall motion at 6-months follow-up. Patients with complete recovery of wall motion abnormalities had significantly reduced peak systolic and peak early diastolic mitral annular velocities compared to HS at 6 months (8.3 cm s(-1) versus 9.9 cm s(-1), P<0.001 for systolic velocity and 9.3 cm s(-1) versus 13.1 cm s(-1), P<0.001 for diastolic velocity, respectively).

CONCLUSION

In patients presenting with a first STEMI, mitral annular systolic and early diastolic velocities assessed by DTI at 6-months follow-up are significantly reduced compared to HS, despite normal standard echocardiographic parameters of LV function. This probably reflects a residual subendocardial damage not detected by conventional echocardiographic methods.

Circumferential Versus Longitudinal Systolic Function in Patients with Hypertension: A Nonlinear Relation

BACKGROUND

Depressed circumferential midwall performance and impaired left ventricular (LV) longitudinal function are both early markers of LV systolic dysfunction in patients with hypertension. The relation between midwall and longitudinal indices in these patients has never been analyzed.

METHODS

In 126 patients with hypertension, midwall fractional shortening (mFS), stress-corrected mFS, M-mode left atrioventricular plane displacement, and tissue Doppler-derived peak mitral annular systolic velocity were determined.

RESULTS

Regression analysis showed that the relations of midwall indices to atrioventricular plane displacement and mitral annular systolic velocity were all nonlinear. Reductions in atrioventricular plane displacement or mitral annular systolic velocity within their higher ranges corresponded to relatively smaller decreases in mFS and stress-corrected mFS. Relative wall thickness was the strongest determinant of the relative efficiency of circumferential and longitudinal LV contraction.

CONCLUSION

The relation between circumferential midwall and longitudinal function in patients with hypertension is nonlinear and dependent on LV geometry. In these patients, systolic impairment occurs earlier in longitudinal than circumferential performance.

Right ventricular systolic function is not the sole determinant of tricuspid annular motion

Maximal tricuspid annular plane systolic excursion (TAPSE) correlates well with right ventricular (RV) function; however, little is known regarding the impact of left ventricular (LV) systolic function on TAPSE. Consequently, TAPSE was examined in 206 patients (105 men; mean age 56 +/- 17 years), and the data were analyzed with respect to RV (RV fractional area change 45 +/- 19%) and LV (56 +/- 17%) systolic function. The mean TAPSE for the population studied was 1.97 +/- 0.72 cm. Although a strong linear correlation was noted between RV fractional area change and TAPSE (r = 0.73, p <0.0001), relative differences with regard to TAPSE were also found. First, the greatest TAPSE was noted only when RV and LV systolic function were normal (2.46 +/- 0.50 cm). Second, patients with reduced RV systolic function had the smallest TAPSE (1.28 +/- 0.48 cm, p <0.0001). Third, patients with normal RV function but reduced LV systolic function had TAPSE (1.91 +/- 0.54 cm, p <0.0001) that was intermediate between that of patients with normal RV and LV systolic function and those with abnormal RV systolic function. Fourth, patients with reduced biventricular function had the smallest TAPSE (1.16 +/- 0.41 cm, p <0.0001). In conclusion, TAPSE is not only determined by RV systolic function but also appears to depend on LV systolic function. TAPSE <2.0 cm is associated with some degree of either RV or LV dysfunction, whereas a value >2.0 cm suggests normal biventricular systolic function.

Assessment of Left Ventricular Ejection Fraction Using Long-Axis Systolic Function Is Independent of Image Quality: A Study of Tissue Doppler Imaging and M-Mode Echocardiography

BACKGROUND

Quantitative assessment of left ventricular ejection fraction (LVEF) is technically difficult in patients with poor image quality (IQ). Mitral annulus velocity assessed by pulsed tissue Doppler imaging (TDI) and mitral annulus motion assessed by M-mode echocardiography has been shown to correlate with LVEF. Furthermore, mitral annulus sites are easy to identify even in patients with poor IQ. The purpose of this study was to determine whether these methods are useful for estimating LVEF in patients with poor IQ.

METHODS

One hundred ten patients underwent TDI and M-mode echocardiography simultaneously. Mitral annulus velocity and mitral annulus motion were obtained from each of the four mitral annulus sites. Mean mitral annular peak systolic velocities (Sm) and mean mitral annular motions (MAM) were calculated by averaging at each site. IQ was defined according to a previous report.

RESULTS

Both Sm and MAM were successfully measured in all patients. Mean Sm and mean MAM correlated with LVEF. These correlations were observed not only in patients with good IQ (p < 0.001, r = 0.61 for mean Sm; p < 0.001, r = 0.61 for mean MAM) or fair IQ (p < 0.001, r = 0.58 for mean Sm; p < 0.001, r = 0.68 for mean MAM) but also in patients with poor IQ (p < 0.05, r = 0.42 for mean Sm, p < 0.001, r = 0.61 for mean MAM). Using optimal cutoff values of mean Sm and mean MAM in each IQ group, sensitivity and specificity for identifying LVEF < 50% were comparable among three IQ groups.

CONCLUSIONS

Assessment of long-axis systolic function by TDI and M-mode echocardiography enables estimation of LVEF even in patients with poor IQ.

Severe tricuspid regurgitation shows significant impact in the relationship among peak systolic tricuspid annular velocity, tricuspid annular plane systolic excursion, and right ventricular ejection fraction

OBJECTIVES

Peak systolic mitral annular velocities correlate with left ventricular ejection fraction (EF) regardless of mitral regurgitation severity. Peak systolic tricuspid annular velocity (RV-Sm) and tricuspid annular plane systolic excursion (TAPSE) are used to assess right ventricular (RV) EF (RVEF). We investigated whether tricuspid regurgitation (TR) affects the relationship among RV-Sm, TAPSE, and RVEF.

METHODS

Patients (n = 625) underwent echocardiography and Doppler tissue studies. Left ventricular EF and RVEF were estimated by Simpson's rule. Because of confounding, we excluded patients with diseases that influence mitral annular motion or left ventricular function. We finally enrolled 225 patients: 125 with mild TR, 50 with moderate TR, and 50 with severe TR. Forty study patients (20 with mild TR, 10 with moderate TR, and 10 with severe TR) received radionuclide ventriculography.

RESULTS

The RVEF estimated by Simpson's method correlated strongly to that estimated by the radionuclide method (r = 0.793, r2 = 0.629, P < .0001). With mild or moderate TR, RV-Sm correlated well to RVEF (mild TR group: r = 0.765, r2 = 0.59, P < .0001; moderate TR group: r = 0.756, r2 = 0.57, P < .0001). RV-Sm had no significant correlation to RVEF in patients with severe TR (r = 0.212, r2 = 0.05, P = .167). Over a range of TR severities, the relationship between TAPSE and RVEF showed a similar trend to that between RV-Sm and RVEF.

CONCLUSION

Severe TR has a significant impact on the relationship between RV-Sm and RVEF and between TAPSE and RVEF. TAPSE and RV-Sm in patients with severe TR show poor correlation to RVEF. When applying Doppler tissue method or TAPSE to assess RV function, severe TR is a significantly confounding factor.

Left Ventricular Systolic Longitudinal Function: Comparison Among Simple M-Mode, Pulsed, and M-Mode Color Tissue Doppler of Mitral Annulus in Healthy Individuals

BACKGROUND

M-mode determination of left ventricular (LV) atrioventricular plane displacement (AVPD) allows a simple assessment of LV longitudinal systolic function. Color tissue Doppler (TD) M-mode-derived AVPD and pulsed TD-derived systolic annular velocity are more sophisticated tools.

OBJECTIVE

We sought to compare these 3 techniques for the analysis of LV longitudinal systolic function.

METHODS

Standard M-mode AVPD, color TD M-mode AVPD, and systolic annular velocity were measured at 4 annular levels in 56 healthy individuals. The time to onset and the electromechanical interval were also determined using each technique.

RESULTS

Standard M-mode AVPD (r = 0.56, P < .0001) and color TD M-mode AVPD (r = .65, P < .0001) showed good correlation with systolic annular velocity. All 3 techniques revealed an inhomogeneous systolic shifting among different annular portions. Systolic intervals showed small discrepancies but high concordance between M-mode techniques and pulsed TD.

CONCLUSIONS

Standard M-mode imaging of the mitral annulus may be considered a reliable method for the assessment of LV longitudinal function.

Cardiopulmonary Exercise Testing Determination of Functional Capacity in Mitral Regurgitation

OBJECTIVES

This study was designed to evaluate prevalence, determinants, and clinical outcome implications of reduced functional capacity (FC) in patients with organic mitral regurgitation (MR).

BACKGROUND

Evaluation of FC by exercise testing is rarely performed in MR because little is known about the clinical determinants and outcome implications of FC.

METHODS

Cardiopulmonary exercise testing (CPET) was prospectively performed in 134 asymptomatic patients with organic MR to assess FC (peak oxygen consumption [VO2]) simultaneously to Doppler-echocardiographic quantitation of MR (effective regurgitant orifice [ERO]) and left ventricular (LV) systolic and diastolic function.

RESULTS

Peak VO2 was 26 +/- 6 ml/kg/min (96 +/- 16% of age-predicted), but varied widely (57% to 145% of predicted) and was markedly reduced (< or =84% of predicted) in 19% of patients. Although ERO of MR was univariately associated with reduced FC (26 vs. 9% with ERO > or =40 vs. <40 mm2), independent determinants of reduced FC were LV diastolic function (higher E/E' ratio, p = 0.006), atrial fibrillation (p = 0.01), and lower forward stroke volume (p = 0.03). Clinical events (death, heart failure, new atrial fibrillation) and clinical events or surgery were more frequent with than without reduced FC (3 years, 36 +/- 14% vs. 13 +/- 4%, p = 0.02; and 66 +/- 11% vs. 29 +/- 5%, p = 0.001, respectively), even adjusting (risk ratios 1.80 and 1.54 respectively, both p < or = 0.03) for age and ERO.

CONCLUSIONS

In asymptomatic organic MR, FC quantitatively assessed by CPET is unexpectedly markedly reduced in one out of every four to five patients. Reduced FC is independently determined by consequences rather than severity of MR and predicts increased subsequent clinical events. Therefore, CPET frequently reveals functional limitations not detected clinically and is an important tool in managing patients with organic MR.

Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

OBJECTIVE

To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction.

METHODS

185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging.

RESULTS

During a median follow up of 32 months (range 24-38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p = 0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p = 0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p = 0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p = 0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p = 0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p = 0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p = 0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p = 0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p = 0.016) emerged as independent predictors of outcome.

CONCLUSIONS

In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.

Systolic and diastolic functions in elderly patients with and without heart failure

BACKGROUND

A considerable number of patients with heart failure (HF) have a normal left ventricular ejection fraction (LVEF). In these subjects, HF has usually been related to diastolic heart failure (DHF), still a frequently overlooked clinical entity.

METHODS

This study reports the clinical, instrumental, and conventional echocardiographic evaluation of 159 consecutive, hospitalized elderly patients, 87 admitted with HF and 72 admitted for other reasons without overt HF.

RESULTS

All of the 87 HF patients had signs of diastolic dysfunction (DDYS), yet 44.8% of them had a normal LVEF. Forty-four of the 72 patients admitted without overt HF (61.1%) had mild DDYS and 14 (19.5%) also had a reduced LVEF. There was a clear relationship between LVEF reduction and the severity of DDYS.

CONCLUSIONS

HF is often a combination of diastolic and systolic function abnormalities. DHF may be difficult to detect in HF subjects with normal LVEF because their DDYS is often mild. However, there are signs of DDYS in all HF patients that increase in severity as LVEF decreases. DDYS could be considered a marker for all forms of HF, especially in elderly patients.

Right ventricular dysfunction in chronic heart failure patients

AIM

To evaluate any differences in haemodynamic and echocardiographic parameters in patients with both left (LV) and right ventricular (RV) systolic dysfunction and in patients with isolated LV systolic dysfunction.

STUDY GROUP

One hundred patients with RV systolic dysfunction defined as peak velocity of tricuspid annular motion in systole (Sa)<11.5 cm/s, and 55 patients without RV systolic dysfunction Sa>11.5 cm/s. All patients had LV systolic dysfunction, LV ejection fraction (EF) below 40%, NYHA II-IV.

METHODS

LV diameters, volumes and EF were measured by echocardiography. Patients underwent tissue Doppler imaging (TDI) of tricuspid annular motion with measurement of peak systolic velocity (Sa), peak early (Ea) and peak late (Aa) diastolic velocities. Right heart catheterization was also performed.

RESULTS

Patients with RV systolic dysfunction did not differ from those without RV systolic dysfunction in terms of LV function. Patients with RV systolic dysfunction had larger RV dimension 30.6+/-5.8 vs. 33.9+/-6.7 mm, p<0.002. The patients with RV systolic dysfunction had higher values on right heart catheterization: MPAP 29.6+/-12.1 vs. 24.9+/-11.4 mm Hg, p<0.02, PCWP 20.8+/-10.0 vs. 17.3+/-9.3 mm Hg, p<0.03, PVR 189.9+/-123.3 vs. 137.7+/-94.9 dyn s cm(-5), p<0.008, CVP 7.7+/-5.6 vs. 5.1+/-3.9 mm Hg, p<0.002. The patients with RV systolic dysfunction had more pronounced diastolic dysfunction measured by TDI: Ea 9.9+/-2.3 vs. 11.4+/-2.5 cm/s, p<0.0001 and Aa 13.1+/-4.0 vs. 16.5+/-4.7 cm/s, p<0.000007.

CONCLUSION

Patients with heart failure and both left and right ventricular systolic dysfunction showed more serious findings on central haemodynamics as well as more pronounced right ventricular diastolic dysfunction than those with isolated left ventricular systolic dysfunction.

Tissue Doppler velocities of mitral annulus and NT-proBNP in patients with heart failure

BACKGROUND

It has been shown that pulsed wave tissue Doppler velocities of mitral annulus correlate well with left ventricular (LV) diastolic and systolic functions. It is not yet clear whether these velocities can be used to estimate left ventricular dysfunction in an unselected population of patients with clinical signs and symptoms of heart failure (HF).

AIM

To determine whether LV mitral annulus velocities measured by tissue Doppler imaging (TDI) correlate with plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with HF.

METHODS AND RESULTS

Early diastolic (E(m)) and systolic (S(m)) TDI velocities of septal and lateral mitral annulus were measured in 50 patients with HF together with other conventional echocardiographic parameters, and compared with plasma NT-proBNP levels. Significant correlations were found between NT-proBNP level and E(m) velocity (r=-0.79), S(m) velocity (r=-0.43), early transmitral to E(m) velocity ratio (r=0.38), LV end diastolic diameter (r=0.29), LV ejection fraction (r=-0.44) and tricuspid regurgitant velocity (r=0.31). In multiple regression model (R(2)=0.733), the E(m) velocity was the most important predictor of NT-proBNP level.

CONCLUSIONS

Early diastolic mitral annulus velocity measured by TDI correlates strongly with plasma NT-proBNP levels, and provides a simple, accurate and reproducible echocardiographic index of heart failure.

Assessment of Left Ventricular Function Using Pulsed Tissue Doppler Imaging in Healthy Dogs and Dogs with Spontaneous Mitral Regurgitation

Pulsed tissue Doppler imaging (pulsed TDI) has been demonstrated to be useful for the estimation of left ventricular (LV) systolic and diastolic functions in various human cardiac diseases. The objectives of this study were to investigate the relationship between pulsed TDI and LV function by using cardiac catheterization in healthy dogs and to evaluate the clinical usefulness of pulsed TDI in dogs with spontaneous mitral regurgitation (MR). The peak early diastolic velocity (E'), peak atrial systolic velocity (A'), and peak systolic velocity (S') were detectable in the velocity profiles of the mitral annulus in all the dogs. In the healthy dogs, S' and E' were correlated with LV peak +dP/dt and -dP/dt, respectively. E' was lower in dogs with MR than in dogs without cardiac diseases. E/E' in the MR dogs with decompensated heart failure was significantly increased in comparison with those with compensated heart failure. The sensitivity and specificity of the E/E' cutoff value of 13.0 for identifying decompensated heart failure were 80% and 83%, respectively. In addition, E/E' was significantly correlated with the ratio of left atrial to aortic diameter. These findings suggest that canine pulsed TDI can be applied clinically for estimation of cardiac function and detection of cardiac decompensation and left atrial volume overload in dogs with MR.

Left and right ventricular adaptation assessed by Doppler tissue echocardiography in athletes

BACKGROUND

Changes induced by intensive training in the morphology and kinetics of both ventricles in athletes (soccer players) were assessed by 2-dimensional echocardiography and Doppler tissue echocardiography (DTE). DTE has yet to find widespread application in sports medicine, and the right ventricle (RV) is often neglected in the examination of athletes. DTE-determined velocities were measured along the short and long axis in the left ventricle (LV) and over the long axis in the RV. Wall displacements (systolic shortenings and diastolic elongations) were computed at each site as time-velocity integrals. Normalized velocities and excursions were calculated with reference to the long and short diastolic dimensions.

METHODS

A total of 20 athletes and 15 age- and sex-matched control subjects were enrolled in the study. All participants underwent history screening, physical examination, electrocardiogram, and blood analysis.

RESULTS

The athletes had significantly greater RV long-axis dimension and LV short-axis dimension than control subjects. LV ejection fraction was similar in the 2 groups. In athletes, peak systolic velocities were significantly increased along the LV short axis and the RV long axis. Early diastolic velocities were significantly increased for the LV short axis and nonsignificantly increased at all other sites. The ratio of these peak velocities to the proper diastolic dimension (fractional or normalized velocities) did not significantly differ between the groups. Time-velocity integrals (ie, wall tissue displacements) were increased in all directions examined in both ventricles, both in systole and early diastole. However, normalized or percent shortenings and elongations were similar in athletes and control subjects.

CONCLUSION

These data suggest that an increase in RV and LV cavity size is associated with higher DTE-reported velocities in athletes. These higher velocities correspond to greater excursions of the muscle segments involved. Normalized velocities and excursions, however, indicate an unchanged fractional shortening, so that contractility has to be considered unaffected in these athletes. We suggest that DTE is instructive in unveiling functional adaptations of the heart in athletes, but questions of data interpretation have to be settled. For example, one should be cautious in comparing absolute velocities between chambers of different size. Nonnormalized velocities may be an objectionable index in the presence of cardiac enlargement.

Tissue Doppler imaging for predicting outcome in patients with cardiovascular disease

PURPOSE OF REVIEW

Tissue Doppler imaging is being increasingly used for assessing global ventricular function in systole and diastole, and for quantifying regional wall motion abnormalities both in systolic heart failure with mechanical dyssynchrony and ischemic heart disease. Its use as a predictive tool is recent and the authors review publications relating to this aspect.

RECENT FINDINGS

Peak early diastolic mitral annular velocity is a powerful predictor of outcome in a variety of cardiovascular conditions and adds incremental value to clinical parameters and standard mitral Doppler inflow velocities. Tissue Doppler imaging can also predict the development of hypertrophic cardiomyopathy in asymptomatic individuals carrying the genetic mutation even before the onset of overt left ventricular hypertrophy. In addition, the standard deviation of the time to peak systolic velocity is a good marker of mechanical asynchrony and can predict reverse remodeling. It may also be useful in identifying individuals with ischemic heart disease and regional wall motion abnormalities who have an adverse outcome.

SUMMARY

Tissue Doppler imaging is a powerful new echocardiographic tool that is now becoming the standard for assessing ventricular function in a variety of situations and diseases.