Effects of Hemodialysis on Tei Index: Comparison between Flow Doppler and Tissue Doppler Imaging

Maternal Left Ventricular Diastolic and Systolic Function during Normal Pregnancy in Saint Bernard Dogs

This study aimed to evaluate maternal left ventricular (LV) systo-diastolic function using conventional and TDI echocardiography and included 10 healthy Saint-Bernard pregnant bitches. M-mode, peak transmitral flow velocities during early diastole (E) and atrial contraction (A), aortic and pulmonic flow, myocardial performance index (MPI), TDI studies (peak myocardial velocities during early diastole (E’), atrial contraction (A’) and peak systole (S’)), and blood pressure were measured at 21 to 28 (T1), 40 (T2) and 60 (T3) days of gestation and four to eight weeks postpartum (T4). Cardiac output and heart rate were 20% and 9% higher at T3, respectively, compared to T4 (p < 0.01). Lateral S’ was 36% higher at T3 than at T1 (p < 0.05). Changes in diastolic function were demonstrated by 10% lower E wave and 15% A wave at T1, compared to T4 (p < 0.05). E’ and A’ were 23% and 42% higher at T3 compared to T4 (p < 0.01). Both lateral E/E’ and E’/A’ were 6% and 19% lower at T3 compared to T1 (p < 0.01 and p < 0.05, respectively). At T3, MPI was 51% and 34% lower when compared to T1 or T2 (p < 0.05). The echocardiographic evaluation of maternal cardiac function is important, as structural, and functional changes occur throughout pregnancy.

Kidney function and the prognostic value of myocardial performance index

A decreased glomerular filtration rate (GFR) is a risk factor for cardiovascular disease even after adjustment for conventional risk factors. The myocardial performance index (MPI) is defined as (isovolumetric relaxation time (IVRT) + isovolumetric contraction time (IVCT))/ejection time (ET). It has been shown to be an independent predictor of cardiovascular events. We hypothesized the MPI could prove valuable for assessing cardiac risk in subjects of the general population with decreased estimated GFR (eGFR). MPI was measured in 1915 subjects from a large general population prospective cohort study using color tissue Doppler imaging (TDI) M-mode through the mitral valve. We compared the prognostic capabilities of the MPI between subjects with eGFR ≥ 75 mL/min/1.73 m² and subjects with eGFR < 75 mL/min/1.73 m² using multivariable adjusted Cox regression models. The composite endpoint was heart failure, myocardial infarction or cardiovascular death. Mean age was 58 years (SD 16.2), 58% were women, 42% had hypertension and 8.3% diabetes. During a median follow-up time of 12.4 years [IQR 10.6-12.7 years] 269 participants reached the combined endpoint. eGFR modified the prognostic capability of MPI (p-value for interaction < 0.001): After multivariable adjustment, MPI remained an independent predictor of the composite endpoint only in participants with eGFR < 75 mL/min/1.73 m²: HR 1.18 (95% CI 1.02-1.38), p = 0.03, vs. in subjects with eGFR ≥ 75 mL/min/1.73 m²: HR 1.14 (95% CI 0.94-1.39), p = 0.17. These results suggest the MPI could be particularly valuable for identifying elevated cardiac risk in individuals from the general population with decreased eGFR.

Septic Cardiomyopathy: From Basics to Management Choices

Septic cardiomyopathy (SCM) is increasingly recognized as a potential complication of septic shock; it is understood to be a reversible left ventricular systolic dysfunction. The presence of SCM in septic shock, in previous studies, infer a poorer prognosis as it significantly increases the mortality rate of patients to 70%-90% and its incidence varies from 18% to 40% of septic shock patients. The pathogenesis is unclear, but believed to be a combination of bacterial toxins, cytokines, nitric oxide, and cardiac mitochondrial dysfunction, that depresses intrinsic cardiac contractility. The presence of SCM can be diagnosed in patients using a bedside transthoracic echocardiogram which typically shows left ventricular ejection fraction <45% and right ventricular dilatation. For management, levosimendan provides a good hemodynamic response without increasing cardiac oxygen demand when compared to dobutamine, while more invasive techniques such as extracorporeal membrane oxygenation, and intra-aortic balloon pulsation are being explored as well as potential rescue strategies for patients with severe SCM.

R-Wave Modified Tissue Doppler Imaging Myocardial Performance Index for the Assessment of Cardiac Function in Children with Congestive Heart Failure: A Feasibility Study

Background

The aim of this study was to evaluate the feasibility of an R-wave modified tissue Doppler imaging (TDI) myocardial performance index (MPI), or MPI TDI-R, for the assessment of cardiac function in children with congestive heart failure (CHF).

Material/Methods

Forty children with CHF and 40 normal children were evaluated using the modified pediatric Ross heart failure grading system. TDI recorded the spectrum of diastolic function at the mitral valve annulus to measure the MPI. Twelve-lead electrocardiogram (ECG) measured the R-wave in the QRS complex, resulting in the modified MPI TDI-R. Correlation between the MPI TDI-R, other echocardiographic indices, and the Ross heart failure grades were analyzed, with reproducibility analysis.

Results

Compared with normal children, the MPI TDI and MPI TDI-R were significantly increased in the pediatric CHF group (P<0.01). The MPI TDI-R was significantly correlated with other indices of cardiac function and Ross grading for CHF in children (r=0.769). The MPI TDI-R showed good correlation with the findings of the MPI TDI, calculated by traditional methods. Receiver-operating characteristic (ROC) curve analysis showed that the MPI TDI-R had a sensitivity of 67.5%, and a specificity of 97.5%. The reproducibility of the MPI TDI-R was confirmed to be superior when compared with the non-modified MPI TDI.

Conclusions

This feasibility study showed that the modified MPI TDI-R, formed by combining the MPI TDI with synchronous surface ECG measurements, was simple to perform, reproducible, and provided a specific index for the assessment of cardiac function in children with CHF.

Right Ventricular Function After Creation of an Atriovenous Fistula in Patients With End Stage Renal Disease

BACKGROUND

Right ventricular (RV) dysfunction is associated with increased risk of heart failure and mortality in end stage renal disease (ESRD) patients. Accumulating evidence suggests an association between atriovenous fistula (AVF) and RV dysfunction; however, there is no adequate data on the relation between AVF characteristics and risk of RV dysfunction after AVF creation.

METHODS

The study included 30 ESRD patients (median age: 44years, 17 male) who had their first autogenous mature AVF. Before and 6months after AVF creation the following were measured: myocardial performance index of RV (MPI-RV) using tissue Doppler imaging echocardiography and flow rate (Qa), feeding artery and receiving vein diameters using colour-flow Doppler ultrasound. Change (Δ) in MPI-RV was calculated by subtracting follow-up value from baseline value. Worsening RV function was defined as Δ MPI-RV>0.015 and high AVF flow as Qa≥950ml/min.

RESULTS

Compared to patients with lower AVF flow, patients with higher flow showed increased Δ in MPI-RV (0.12 vs. -0.03, p=0.04), basal RV diameter (0.3 vs. -0.02cm, p=0.014), left ventricular end diastolic volume index (9.9 vs. 0ml/m², p=0.004) and left atrial volume index (3 vs. 1ml/m², p=0.016). Among all clinical, echocardiographic and AVF-related parameters, univariate predictors of worsening of RV function were: high Qa, upper arm AVF, and large feeding artery diameter at baseline. Δ MPI-RV showed significant correlations with feeding artery diameter at baseline (r=0.46, p=0.01), and Qa (0.37, p=0.04) and no significant correlation with pulmonary artery pressures. Qa≥950ml/min, feeding artery diameter at baseline≥4mm and upper arm AVF can predict worsening of RV function with 73%, 73%, 75% sensitivity and 67%, 67%, 70% specificity, respectively.

CONCLUSIONS

In patients with ESRD, higher AVF flow adversely affects RV remodelling, manifested as increased size and worsening function. Predictors of worsening of RV function are: higher AVF flow rate, AVF in the upper arm, and large feeding artery diameter.

Tei index for monitoring changes in left heart function in patients with cirrhosis before and after propranolol treatment

AIM

To investigate the clinical value of Tei index in monitoring the changes of left heart function in patients with cirrhosis before and after propranolol treatment.

METHODS

One hundred and forty-three patients with cirrhosis treated at Tongde Hospital of Zhejiang Province from March 2015 to November 2017 were divided into either a control group or a study group. The control group (n = 70), including 29 cases with Child-Pugh grade A liver function, 20 cases of grade B, and 21 cases of grade C, was given routine treatments (liver protection, diet control, and so on). The study group (n = 73), including 27 cases with Child-Pugh grade A liver function, 22 cases of grade B, and 24 cases of grade C, was given propranolol on the basis of routine treatments. Eighty healthy volunteers who received physical examination in the same period were included as a normal control group. Tei index was measured in all subjects before and 1 mo after treatment.

RESULTS

Before treatment, Tei index was significantly higher in the study group and control group than in the normal control group (0.48 ± 0.13, 0.49 ± 0.13 vs 0.32 ± 0.14, P < 0.05). After treatment, Tei index in the study group was significantly lower than that before treatment (0.39 ± 0.12 vs 0.48 ± 0.13, P < 0.05) and that in the control group (0.39 ± 0.12 vs 0.47 ± 0.10, P < 0.05). After treatment, Tei index in patients with Child-Pugh grade A and B liver function in the study group were significantly lower than those before treatment (0.33 ± 0.07 vs 0.46 ± 0.11, 0.34 ± 0.10 vs 0.48 ± 0.15, P < 0.05), while Tei index in patients with grade C liver function in the study group did not differ significantly between before and after treatment (0.49 ± 0.13 vs 0.51 ± 0.13, P > 0.05).

CONCLUSION

Tei index can objectively and sensitively reflect the change of left heart function in patients with cirrhosis, and is a simple and effective index to evaluate the efficacy of propranolol.

Left ventricular dysfunction by conventional and tissue Doppler echocardiography in pediatric hemodialysis patients: relation with plasma brain natriuretic peptide levels

INTRODUCTION

Tissue Doppler imaging (TDI) is a relatively new echocardiography method in children with chronic kidney disease (CKD). The aims of this study were to evaluate left ventricular (LV) diastolic function in pediatric CKD patients using conventional pulsed-wave Doppler echocardiography (cPWD) and TDI methods and correlate them with BNP levels.

MATERIAL AND METHODS

Thirty children on regular hemodialysis (HD) were included. Left ventricular systolic and diastolic indices and BNP levels were measured immediately before and after HD.

RESULTS

After HD, LV and left atrium diameters were significantly decreased (p < 0.001 and p < 0.001, respectively). Transmitral E velocity and E/A ratio decreased (p < 0.001 and p < 0.001, respectively). Also, there were significant decreases in the early diastolic velocity E' of LV wall, septal wall, and anterior wall (p = 0.001, p = 0.004 and p < 0.001, respectively). Mean E/E' ratio and ratios of septal and lateral walls were decreased significantly (p = 0.004, p = 0.002 and p = 0.017, respectively). BNP levels decreased significantly during HD when comparing concentrations before and after HD (p < 0.001). BNP strongly correlated with LV diastolic function indices (before HD: mean E/E' (r = 0.401, p = 0.028), lateral E/E" (r = 0.291, p = 0.025), septal E'(r = -0.398, p = 0.029), lateral wall E' (r = -0.452, p = 0.012) and mean E' (r = -0.469, p = 0.009), after HD: mean E/E' (r = 0.38, p = 0.038) and lateral E/E" (r = 0.474, p = 0.008) and lateral wall E' (r = -0.270, p = 0.037)).

CONCLUSIONS

The cPWD and TDI-derived LV indices are influenced by HD. The diagnostic utility of BNP in the presence of deteriorating renal function may be compromised to some extent.

Myocardial performance index in hypertensive disorders of pregnancy: The relationship between blood pressures and angiogenic factors

OBJECTIVE

To study the association between cardiac function measured by myocardial performance index (MPI), blood pressures and angiogenic factors measured at the time of echocardiography in patients with and without hypertensive disorders of pregnancy (HDP).

METHODS

We prospectively studied 189 pregnant women and evaluated whether changes in cardiac function observed on echocardiography were correlated with higher blood pressures and whether higher blood pressures were associated with antiangiogenic proteins (soluble fms-like tyrosine kinase, sFlt1; soluble endoglin, sEng). Comprehensive echocardiograms, including measurement of MPI, were performed on all patients. sFlt1 and sEng levels were measured using enzyme-linked immunosorbent assay.

RESULTS

Overall, 189 patients were divided into tertiles based on mean arterial pressure (MAP). The MPI was worst in tertile 3 (0.50 ± 0.15) compared to tertile 1 (0.42 ± 0.10), p = 0.0004. sFlt1 (pg/ml) and sEng (ng/ml) were highest in tertile 3 compared to tertile 1: 15055.37 vs. 1623.01 and 33.06 vs. 8.15, respectively, with p-value <0.001. In crude multivariate regression analysis, MAP was positively correlated with MPI (r = 0.32, p < 0.001), GLS (r = 0.54, p < 0.001), sFlt1 (r = 0.60, p < 0.001) and sEng (r = 0.61, p < 0.001). After adjustment for confounders, these relationships persisted between MAP and MPI (r = 0.31, p = 0.0003), GLS (r = 0.46, p < 0.001), sFlt1 (r = 0.56, p < 0.001) and sEng (r = 0.58, p < 0.001).

CONCLUSION

Mean arterial pressure correlates with worsening cardiac function as measured by MPI and serum levels of angiogenic factors. Further studies are needed to evaluate whether a reduction in blood pressure will reverse changes in MPI or reduce levels of angiogenic proteins seen among women with HDP.

Interval Changes in Myocardial Performance Index Predict Outcome in Severe Sepsis

OBJECTIVES

Septic cardiomyopathy is a well-described consequence of septic shock and is associated with increased sepsis-related mortality. The myocardial performance index (MPI), a parameter derived from echocardiographic tissue Doppler measurements, allows for a more sensitive assessment of global cardiac function than do traditional metrics for cardiac function. The authors hypothesized that changes in left ventricular MPI in patients with severe sepsis would be associated with a higher 90-day mortality.

DESIGN

Prospective, observational study.

SETTING

Intensive care units of a tertiary medical center.

PARTICIPANTS

The study comprised 47 patients admitted with new diagnoses of severe sepsis or septic shock.

INTERVENTIONS

All patients underwent transthoracic echocardiograms with assessment of MPI at enrollment and 24 hours later. Hemodynamic data and information on sepsis-related mortality were collected. In the primary analysis, the association between change in MPI from enrollment to 24 hours and sepsis-related 90-day mortality was assessed.

MEASUREMENTS AND MAIN RESULTS

Of the 47 patients enrolled, 30 demonstrated an improvement in MPI from 0 to 24 hours ("improved" group), and MPI worsened in the remaining 17 patients ("worsened" group). Despite no significant differences in ejection fraction or severity of illness, the median MPI at enrollment in the "improved" group was higher than baseline values in the "worsened" group (p = 0.005). A worsening MPI over the 24-hour study interval was associated with increased mortality at 90 days (p = 0.04), which remained significant (hazard ratio 3.72; 95% confidence interval 1.12-12.41; p = 0.03) after adjusting for severity of illness (Acute Physiology and Chronic Health Evaluation II score), intravenous fluids, and vasopressor use.

CONCLUSIONS

In patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock, a worsening MPI during the first 24 hours after intensive care unit admission was associated with higher 90-day mortality.

Assessment of left ventricle systolic and diastolic functions in schizophrenia patients

The objective of the study was to scrutinize in detail the changes that occur in left ventricle (LV) systolic and diastolic functions using echocardiography in patients with at least 5 years of history and 40 healthy volunteers matching the patients in age and gender, who were enrolled in a cross-sectional study. All cases were examined with Tei Index, an index that could assess LV systolic and diastolic functions in conjuction, and with LV ejection fraction (LVEF) that assesses systolic function. In addition, Mitral E and A wave velocities, Isovolemic relaxation time (IVRT), Tissue Doppler Em (peak early motion) and Am (peak after motion) waves, which evaluate diastolic functions were measured. Tei Index was calculated as 0.61±0.19 in the patient group, and as 0.39±0.10 in the control group and the difference was statistically significant (p<0.001). LVEF was measured as 58%±5 in the patient group, and as 62%±3 in the control group and the difference was statistically significant (p<0.001). Also the IVRT values were significantly different between the tissue Doppler Em and Em/Am ratio among the groups (p<0.001). Echocardiographic myocardial performance, LV systolic and diastolic functions in schizophrenia patients was found to be worse than those of the control group.