Effects of acute myocardial infarction on the displacement of the atrioventricular plane: an echocardiographic study

Left ventricular longitudinal shortening: relation to stroke volume and ejection fraction in ageing, blood pressure, body size and gender in the HUNT3 study

Background

Aims of this cross-sectional study were to assess: the relative contribution of left ventricular (LV) systolic long-axis shortening (mean mitral annular plane systolic excursion, MAPSE) to stroke volume (SV), the mechanisms for preserved ejection fraction (EF) despite reduced MAPSE, the age dependency of myocardial volume and myocardial systolic compression.

Methods

Linear dimensions and longitudinal and cross-sectional M-modes were acquired in 1266 individuals without history of heart disease, diabetes or known hypertension from the third wave of the Nord-Trøndelag Health Study. Measurements were entered into a half-ellipsoid LV model for volume calculations, and volumes were related to age, body size (body surface area, BSA), sex and blood pressure (BP).

Results

Mean BP and proportion with hypertensive values increased with increasing age. MAPSE contributed to 75% of SV, with no relation to age or BSA as both MAPSE and SV decreased with increasing age. LV end-diastolic volume (LVEDV) and SV increased with BSA and decreased with higher age; EF was not related to age or BSA. Myocardial volume increased with higher age and BSA, with an additional gender dependency. The association of age with myocardial volume was not significant when corrected for BP, while both systolic and diastolic BP were significant associated with myocardial volume. Myocardial compression was less than 3%.

Conclusions

MAPSE contributes approximately 75% and short axis shortening 25% to SV. Both decline with age, but their percentage contributions to SV are unchanged. EF is preserved by the simultaneous decrease in LVEDV and SV. Myocardial volume is positively associated with age, but this is only related to higher BP, which may have implications for BP treatment in ageing. The myocardium is near incompressible.

Decreased atrioventricular plane displacement after acute myocardial infarction yields a concomitant decrease in stroke volume

Acute myocardial infarction (AMI) can progress to heart failure, which has a poor prognosis. Normally, 60% of stroke volume (SV) is attributed to the longitudinal ventricular shortening and lengthening evident in the atrioventricular plane displacement (AVPD) during the cardiac cycle, but there is no information on how the relationship changes between SV and AVPD before and after AMI. Therefore, the aim of this study was to determine how SV depends on AVPD before and after AMI in two swine models. Serial cardiac magnetic resonance imaging was carried out before and 1–2 h after AMI in a microembolization model (n = 12) and an ischemia-reperfusion model (n = 14). A subset of pigs (n = 7) were additionally imaged at 24 h and at 7 days. Cine and late gadolinium enhancement images were analyzed for cardiac function, AVPD measurements and infarct size estimation, respectively. AVPD decreased (P < 0.05) in all myocardial regions after AMI, with a concomitant SV decrease (P < 0.001). The ischemia-reperfusion model affected SV to a higher degree and had a larger AVPD decrease than the microembolization model (−29 ± 14% vs. −15 ± 18%; P < 0.05). Wall thickening decreased in infarcted areas (P < 0.001), and A-wave AVPD remained unchanged (P = 0.93) whereas E-wave AVPD decreased (P < 0.001) after AMI. We conclude that AVPD is coupled to SV independent of infarct type but likely to a greater degree in ischemia-reperfusion infarcts compared with microembolization infarcts. AMI reduces diastolic early filling AVPD but not AVPD from atrial contraction. These findings shed light on the physiological significance of atrioventricular plane motion when assessing acute and subacute myocardial infarction.

NEW & NOTEWORTHY The link between cardiac longitudinal motion, measured as atrioventricular plane displacement (AVPD), and stroke volume (SV) is investigated in swine after acute myocardial infarction (AMI). This cardiac magnetic resonance study demonstrates a close coupling between AVPD and SV before and after AMI in an experimental setting and demonstrates that this connection is present in ischemia-reperfusion and microembolization infarcts, acutely and during the first week. Furthermore, AVPD is equally and persistently depressed in infarcted and remote myocardium after AMI.

Left ventricular global strains by linear measurements in three dimensions: interrelations and relations to age, gender and body size in the HUNT Study

Background

Strain is a relative deformation and has three dimensions, in the left ventricle (LV) usually longitudinal (ε_L), transmural (ε_T) and circumferential (ε_C) strain. All three components can be measured generically by the basic systolic and diastolic dimension measures of LV wall length, wall thickness and diameter. In this observational study we aimed to study the relations of normal generic strains to age, body size and gender, as well as the interrelations between the three strain components.

Methods

Generic strains derived from dimension measures by longitudinal and cross-sectional M-mode in all three dimensions were measured in 1266 individuals without heart disease from the Nord-Trøndelag Health Study.

Results

The mean ε_L was −16.3%, ε_C was −22.7% and ε_T was 56.5%. Normal values by age and gender are provided. There was a gradient of ε_C from the endocardial, via the midwall to the external level, lowest at the external. All strains decreased in absolute values by increasing body surface area (BSA) and age, relations were strongest for ε_L. Gender differences were mainly a function of BSA differences. The three strain components were strongly interrelated through myocardial incompressibility.

Conclusions

Global systolic strain is the total deformation of the myocardium; the three strain components are the spatial coordinates of this deformation, irrespective of the technology used for measurement. Normal values are method-dependent and not normative across methods. Interrelation of strains indicates a high degree of myocardial incompressibility and that longitudinal strain carries most of the total information.

Mitral Annular Plane Systolic Excursion as a Predictor of Mortality in Children With Septic Shock

OBJECTIVES

Myocardial dysfunction is well recognized in severe sepsis and septic shock. Echocardiography provides rapid, noninvasive, and bedside evaluation of cardiac function in patients with hemodynamic instability. Mitral annular plane systolic excursion is an M-mode-derived echocardiographic variable used to assess longitudinal left ventricular systolic function. No data are available about the uses of mitral annular plane systolic excursion in children with septic shock. Therefore, we aimed to assess the prognostic significance of mitral annular plane systolic excursion in children with septic shock and to correlate it with the most commonly used measures of left ventricular systolic function and myocardial injury.

DESIGN

A prospective cohort study.

SETTING

The study carried out at the PICU of Menoufia University Hospital in the period from March 2015 to September 2016.

PATIENTS

We serially enrolled 50 children with septic shock.

INTERVENTIONS

Complete diagnostic workup was performed for each patient including calculation of Pediatric Risk of Mortality III score. Transthoracic echocardiography was done to obtain mitral annular plane systolic excursion and the left ventricular ejection fraction measurement within 24 hours of inclusion then repeated on third and fifth days. Patients were followed up until hospital discharge or death. The predictive power of mitral annular plane systolic excursion was determined using the receiver operating characteristic curve.

MEASUREMENTS AND MAIN RESULTS

Mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors (p < 0.001). Receiver operating characteristic curve analysis showed an area under the curve of 0.892 for mitral annular plane systolic excursion on day 1. The cut-off point was 7.9 mm with 82.76% sensitivity and 80.95% specificity. Furthermore, follow-up of the patient's systolic function showed that mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors on days of follow-up, whereas left ventricular ejection fraction was not significantly different between survivors and nonsurvivors at any day. Mitral annular plane systolic excursion was positively correlated with left ventricular ejection fraction (p = 0.044) and duration of hospital stay (p < 0.001) and negatively correlated with Pediatric Risk of Mortality III score (p < 0.001) and cardiac troponin I level (p < 0.001).

CONCLUSIONS

Measurement of mitral annular plane systolic excursion at admission added a prognostic value in septic shock children. Compared with the left ventricular ejection fraction, longitudinal systolic function might be more sensitive in the detection of myocardial dysfunction in critically ill children and should receive more attention.

Value of mitral annular plane systolic excursion in the assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization

Background

Mitral annular plane systolic excursion (MAPSE) is an M-mode derived echocardiographic marker of left ventricular longitudinal function, the aim of this study is to evaluate the value of MAPSE in assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.

Methods

The study included 50 patients with ischemic cardiomyopathy with ejection fraction (EF) ≤35%, the patients presented to echocardiography laboratory for dobutamine stress echocardiography (DSE) to assess viability and contractile reserve before revascularization, patients with primary valvular disease, and those with significant mitral annular calcifications were excluded from the study. A low dose DSE was done to all patients using standardized incremental infusions of 5, 10, and 20 μg/kg/min and the following parameters were measured at both baseline and peak dose, (EF, wall motion score index(WMSI) and MAPSE). Contractile reserve was measured as the difference between the low dose and baseline values of the EF and WMSI.

Results

The study included 50 patients aged 55.08 ± 7.15 years, 94% were males, the DSE protocol was complete in all patients without serious side effects. A total of eight hundred segments were analyzed, at baseline 65% were dysfunctional including 31.2% hypokinetic, 28.8% were akinetic, and 5% were dyskinetic. At low dose study 70% of the dysfunctional myocardium showed viability, EF increased significantly from 30.84 ± 4.56 to 42.24 ± 8.15%, p < 0.001, the WMSI reduced significantly from 1.92 ± 0.33 to 1.47 ± 0.39, and MAPSE increased significantly from 1.02 ± 0.23 to 1.30 ± 0.30 mm. MAPSE showed a significant positive correlation with EF at both baseline and low dose study (r = 0.283, p = 0.046 & r = 0.348, p = 0.013) respectively and a significant negative correlation with WMSI at both baseline and low dose study (r = −0.3, p = 0.034 & r = −0.409, p = 0.003), respectively. By ROC curve analysis we found that Δ MAPSE ≥2 mm can predict contractile reserve at Δ EF >10% (AUC = 0.6, sensitivity 67.86, specificity 59.09), and Δ MAPSE ≥1.8 mm can predict contractile reserve at ΔWMSI ≤0.20 (AUC = 0.61, sensitivity 65.5, specificity 75.6).

Conclusions

MAPSE is a rapid simple quantitative echocardiographic method that can asses contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.

Predictors of transient left ventricular dysfunction following transcatheter patent ductus arteriosus closure in pediatric age

OBJECTIVES

To evaluate the left ventricular function before and after transcatheter percutaneous patent ductus arteriosus (PDA) closure, and to identify the predictors of myocardial dysfunction post-PDA closure if present.

INTERVENTIONS

Transcatheter PDA closure; conventional, Doppler, and tissue Doppler imaging; and speckle tracking echocardiography.

OUTCOME MEASURES

To determine the feasibility and reliability of tissue Doppler and myocardial deformation imaging for evaluating myocardial function in children undergoing transcatheter PDA closure.

PATIENTS AND METHODS

Forty-two children diagnosed with hemodynamically significant PDA underwent percutaneous PDA closure. Conventional, Doppler, and tissue Doppler imaging, and speckle-derived strain rate echocardiography were performed at preclosure and at 48 hours, 1 month, and 6 months postclosure. Tissue Doppler velocities of the lateral and septal mitral valve annuli were obtained. Global and regional longitudinal peak systolic strain values were determined using two-dimensional speckle tracking echocardiography.

RESULTS

The median age of the patients was 2 years and body weight was 15 kg, with the mean PDA diameter of 3.11 ± 0.99 mm. M-mode measurements (left ventricular end diastolic diameter, left atrium diameter to aortic annulus ratio, ejection fraction, and shortening fraction) reduced significantly early after PDA closure (p < 0.001). After 1 month, left ventricular end diastolic diameter and left atrium diameter to aortic annulus ratio continued to decrease, while ejection fraction and fractional shortening improved significantly. All tissue Doppler velocities showed a significant decrease at 48 hours with significant prolongation of global myocardial function (p < 0.001) and then were normalized within 1 month postclosure. Similarly, global longitudinal strain significantly decreased at 48 hours postclosure (p < 0.001), which also recovered at 1 month follow-up. Preclosure global longitudinal strain showed a good correlation with the postclosure prolongation of the myocardial performance index.

CONCLUSION

Transcatheter PDA closure causes a significant decrease in left ventricular performance early after PDA closure, which recovers completely within 1 month. Preclosure global longitudinal strain can be a predictor of postclosure myocardial dysfunction.

Longitudinal shortening remains the principal component of left ventricular pumping in patients with chronic myocardial infarction even when the absolute atrioventricular plane displacement is decreased

Background

The majority (60%) of left ventricular (LV) stroke volume (SV) is generated by longitudinal shortening causing apical atrioventricular plane displacement (AVPD) in systole. The remaining SV is caused by radial inward motion of the epicardium both in the septal and the lateral wall. We aimed to determine if these longitudinal, septal and lateral contributions to LVSV are changed in patients with chronic myocardial infarction (MI).

Methods

Patients with a chronic (>3 months) ST-elevation MI in the left anterior descending (LAD, n = 20) or right coronary artery (RCA, n = 16) and healthy controls (n = 20) were examined with cardiovascular magnetic resonance (CMR). AVPD was quantified in long axis cine CMR images and LV volumes and dimensions in short axis cine images.

Results

AVPD was decreased both in patients with LAD-MI (11 ± 1 mm, p < 0.001) and RCA-MI (13 ± 1 mm, p < 0.05) compared to controls (15 ± 0 mm). However, the longitudinal contribution to SV was unchanged for both LAD-MI (58 ± 3%, p = 0.08) and RCA-MI (59 ± 3%, p = 0.09) compared to controls (64 ± 2%). The preserved longitudinal contribution despite decreased absolute AVPD was a results of increased epicardial dimensions (p < 0.01 for LAD-MI and p = 0.06 for RCA-MI). In LAD-MI the septal contribution to LVSV was decreased (5 ± 1%) compared to both controls (10 ± 1%, p < 0.01) and patients with RCA-MIs (10 ± 1%, p < 0.01). The lateral contribution was increased in LAD-MI patients (44 ± 3%) compared to both RCA-MI (35 ± 2%, p < 0.05) and controls (29 ± 2%, p < 0.001).

Conclusion

Longitudinal shortening remains the principal component of left ventricular pumping in patients with chronic MI even when the absolute AVPD is decreased.

Assessment of global left ventricular excursion using three-dimensional dobutamine stress echocardiography to identify significant coronary artery disease

BACKGROUND

Quantitative three-dimensional (3D) dobutamine stress echocardiography (DSE) for myocardial ischemia detection may be an adjuvant to left ventricular (LV) wall-motion analysis. The aim of the current study was to assess the association between global 3D LV excursion during DSE and the presence of significant coronary artery disease (CAD) on coronary angiography.

METHODS

Three-dimensional DSE was performed in 40 patients (67±12 years, 68% male) who underwent subsequent coronary angiography (median 1.6 months later). Using 3D echocardiography, global LV excursion was measured (in a total of 680 segments) at rest and peak dose and the change between stages was calculated (peak-rest=∆global LV excursion). Significant CAD was defined as >70% stenosis on coronary angiography.

RESULTS

In total, 25 patients (63%) demonstrated significant CAD on coronary angiography. At rest, global LV excursion was similar in patients with and without significant CAD (5.1±0.2 vs 5.0±0.2 mm, P=.74). However, patients with significant CAD demonstrated a worsening in global LV excursion from rest to peak stress (from 5.1±0.2 to 4.1±0.2 mm, P<.001), while global LV excursion in patients without significant CAD remained unchanged (from 5.0±0.2 to 5.5±0.2 mm, P=.10). After adjusting for clinically relevant characteristics, ∆global LV excursion was independently associated with significant CAD (odds ratio 0.29, 95% confidence interval 0.12-0.72, P=.008).

CONCLUSIONS

Analysis of 3D echocardiographic LV excursion at global level on full-protocol DSE may be a helpful tool to detect CAD on coronary angiography.

Early Ventricular Dysfunction After Anthracycline Chemotherapy in Children

The aim of this study was to determine the effect of induction dose of anthracycline chemotherapy on the biventricular function among children with acute hematological malignancies (AHM) using tissue Doppler imaging (TDI) and 2D speckle tracking echocardiography (2D-STE). Thirty pediatric patients with AHM and a mean age of 9.24 ± 4.14 years performed conventional echocardiography, TDI and 2D-STE. After induction chemotherapy, the RV showed mainly a diastolic alteration in its function manifested in significant reduction in the tricuspid TDI-derived E' and E'/A' ratio compared with the baseline (20.40 ± 3.81 vs. 17.47 ± 3.87 cm/s, p = 0.001, 1.29 ± 0.27 vs. 1.03 ± 0.37, p < 0.01, respectively), while the TDI-derived RV MPI and isovolumetric relaxation time of RV were significantly increased (0.32 ± 0.06 vs. 0.36 ± 0.08, p < 0.01, 24.73 ± 8.62 vs. 28.47 ± 11.51 ms, p < 0.05, respectively). The LV showed post-chemotherapy mainly an alteration in its longitudinal systolic function in the form of a reduction in MAPSE (13.61 ± 2.00 vs. 11.95 ± 1.75 mm; p < 0.001), TDI-derived systolic velocity of lateral mitral annulus (10.98 ± 2.34 vs. 10.03 ± 1.83 cm/s, p < 0.05), 2D-STE-derived global longitudinal strain (-21.58 ± 2.54 vs. -19.18 ± 3.59 %, p = 0.001) and 2D-STE-derived global longitudinal strain rate (-1.76 ± 0.22 vs. 1.55 ± 0.29 1/s, p < 0.05), with preservation of LV diastolic function when compared to baseline. TDI and 2D-STE could be used for early detection of anthracycline-induced cardiotoxicity in the pediatric age group. Early after induction chemotherapy, the RV develops mainly diastolic dysfunction, while the LV showed a relative longitudinal systolic impairment.

Long axis strain by MRI and echocardiography in a postmyocardial infarct population

PURPOSE

To compare long axis strain (LAS) by magnetic resonance imaging (MRI) and echocardiography in a postinfarct patient population. Long axis left ventricle (LV) function is a sensitive index of incipient heart failure by echocardiography, but is less well established in MRI. LAS is an index of global LV function, which is easily assessed in cine loops provided by most cardiac MRI protocols.

MATERIALS AND METHODS

In all, 116 patients (57 ± 9 years) were studied the same day using echocardiography and MRI 7.4 ± 4.1 months after a first myocardial infarction. LV length was measured in end diastole and end systole in conventional cine images with a temporal resolution of 50 msec or less, and LAS (%) was calculated as the change in LV length, relative to end diastole. Infarct mass was assessed by contrast-enhanced MRI.

RESULTS

LAS was progressively reduced in patients with larger infarcts, and demonstrated good correlations with infarct mass (r = 0.55, P < 0.01). There was a good agreement between LAS assessed by echocardiography and MRI (r = 0.77, P < 0.01), and between LAS by MRI and speckle tracking strain by echocardiography (r = 0.74, P < 0.01).

CONCLUSION

LAS is an index that allows measurement of LV long axis function by conventional cine MRI.

Mitral annular displacement by Doppler tissue imaging may identify coronary occlusion and predict mortality in patients with non-ST-elevation myocardial infarction

BACKGROUND

Mitral annular displacement (MAD) is a simple marker of left ventricular (LV) systolic function. The aim of this study was to test the hypothesis that MAD can distinguish patients with non-ST-segment elevation myocardial infarctions (NSTEMIs) from those with significant coronary artery disease without infarctions, identify coronary occlusion, and predict mortality in patients with NSTEMIs. MAD was compared with established indices of LV function.

METHODS

In this retrospective study, 167 patients with confirmed NSTEMIs were included at two Scandinavian centers. Forty patients with significant coronary artery disease but without myocardial infarctions were included as controls. Doppler tissue imaging was performed at the mitral level of the left ventricle in the three apical planes, and velocities were integrated over time to acquire MAD. LV ejection fraction, global longitudinal strain (GLS), and wall motion score index were assessed according to guidelines.

RESULTS

MAD and GLS could accurately distinguish patients with NSTEMIs from controls. During 48.6 ± 12.1 months of follow-up, 22 of 167 died (13%). MAD, LV ejection fraction, and GLS were reduced and wall motion score index was increased among those who died compared with those who survived (P < .001, P < .001, P < .001, and P = .02, respectively). Multivariate Cox proportional-hazards analyses revealed that MAD was an independent predictor of death (hazard ratio, 1.36; 95% confidence interval, 1.07-1.73; P = .01). MAD and GLS were reduced and wall motion score index was increased in patients with coronary artery occlusion compared with those without occlusion (P = .006, P = .001, and P = .02), while LV ejection fraction did not differ (P = .20).

CONCLUSIONS

MAD accurately identified patients with NSTEMIs, predicted mortality, and identified coronary occlusion in patients with NSTEMIs.

Left ventricle longitudinal deformation assessment by mitral annulus displacement or global longitudinal strain in chronic ischemic heart disease: are they interchangeable?

BACKGROUND

Increasing infarct mass is associated with impaired prognosis in chronic ischemic heart disease. Global strain by echocardiographic assessment relates closely to infarct mass assessed by delayed enhancement magnetic resonance imaging but requires deformation analysis in a 16-segment model of the left ventricular. Mitral annular (MA) displacement reflects longitudinal left ventricular deformation and could provide similar information.

METHODS

Global longitudinal strain and MA displacement by Doppler tissue imaging were assessed in 61 patients 9 months after first myocardial infarctions and compared with global myocardial infarct mass assessed using contrast-enhanced magnetic resonance imaging.

RESULTS

Both indices significantly separated medium-sized infarcts from small or large infarcts (P < .05) and correlated significantly with global infarct mass (P < .01 for both). There was a good correlation between global strain and MA displacement (r = 0.65, P < .01). The sensitivities and specificities to identify myocardial infarcts differed only slightly among the indices, but global longitudinal strain tended to be the best.

CONCLUSIONS

Longitudinal deformation by global strain or MA displacement correlated well with myocardial infarct mass and could discriminate between different extents of myocardial infarctions. Global longitudinal strain tended to be better, especially for the identification of the smallest infarcts.

Separating the left cardiac ventricle from the atrium in short axis MR images using the equation of the atrioventricular plane

Short axis (SA) images obtained from cardiac magnetic resonance imaging are used to advantage in the calculation of important clinical parameters such as the ejection fraction and stroke volume (SV). A prerequisite for these calculations is the separation of the left ventricle and the left atrium. When only using the information seen in the SA images this separation can be a source of error due to the through-plane motion of the basal part of the left ventricle. In this study a method is proposed where the separation of the left ventricle and the atrium is performed by identifying the intersections of the atrioventricular plane in the SA images. The equation of the atrioventricular plane was determined in both systole and diastole using long axis and four chamber image views. Stroke volumes were measured in 20 patients using SA images where the endocardium had been delineated. The SV obtained using the new method was compared with quantitative flow measurements and the conventional technique for calculation of SV from SA images, respectively. The agreement of SV was, according to Bland-Altman analysis, 2.0 ml (95% CI -12.0 to 15.9 ml) in comparison with the flow measurements and 2.2 ml (95% CI -9.2 to 13.6 ml) compared to the conventional method. Inter- and intra-observer variability, when using the new proposed method, was small. This study shows that the identification of the left atrioventricular plane in SA images can be used in the separation of the left atrium and ventricle.

Ventricular endocrine and mechanical function following thrombolysis for acute myocardial infarction

OBJECTIVE

The objective of this study was to assess natriuretic peptide release following acute myocardial infarction, and its relationship with ventricular function.

METHODS

A total of 44 patients with acute myocardial infarction were studied; 13 anterior, age (57+/-12 years) and 31 inferior, age (58+/-12 years). Peptide levels and left ventricular function by echocardiography were assessed at admission and on days 7 and 30 after thrombolysis. Healthy volunteers (n=21) served as controls.

RESULTS

Atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) levels rose from admission to day 7 (p=0.002). While ANP remained elevated at day 30 in both groups, BNP levels fell in patients with anterior myocardial infarction (p=0.03). Left ventricular fractional shortening was reduced at admission in the two groups (p=0.01) but returned towards normal in 7 days (p=0.001) in inferior myocardial infarction and in 30 days in anterior myocardial infarction (p=0.02). Left ventricular long axis amplitude was universally reduced at admission (p=0.01) and remained abnormal at day 30 (p=0.01) in both groups. At day 7, BNP and ANP levels inversely correlated with long axis amplitude of lateral wall in anterior myocardial infarction; (r=-0.7, p=0.01). BNP correlated inversely with fractional shortening in anterior myocardial infarction (r=-0.7, p=0.01) at day 30.

CONCLUSION

The elevated peptide levels at 7 days post-myocardial infarction correlate with reduced mechanical activity of the adjacent noninfarcted segment. Natriuretic peptides release seem to be related to failure of compensatory hyperdynamic activity of the noninfarcted area rather than directly from the injured myocardial segments.

Maximum longitudinal relaxation velocity of the left ventricle: its clinical value and relationship with NT-proBNP plasma levels in heart failure

BACKGROUND

M-mode recordings of the mitral annulus to measure the maximum ascending velocity during early diastole as an expression of maximum longitudinal relaxation velocity of the left ventricle (RVm) can be used as an index of left ventricular (LV) diastolic function. The purpose of this study was to determine the relationship of RVm with LV functional parameters in patients with heart failure, with N-terminal pro-brain natriuretic peptide (NT-proBNP) plasma levels, and with their functional classification.

METHODS AND RESULTS

RVm was recorded in 97 patients by M-mode echocardiography. Patients were classified according to the New York Heart Association (NYHA) and the concentration of NT-proBNP was determined. Patients with ejection fraction (EF)>40 showed a significant correlation between RVm and mitral annulus motion (MAM), mitral flow propagation velocity, E/A, age, deceleration time (DT), and NT-proBNP. In patients with EF<or=40, RVm correlated significantly with MAM, EF, and NT-proBNP. RVm values were higher in NYHA class I compared to II and III, P<0.0001.

CONCLUSIONS

RVm correlates better with functional parameters in patients with EF>40, though its relationship with NT-proBNP both in patients with EF>or<or=40 is to be highlighted. Correlation between RVm and NT-proBNP is influenced by age, EF, and E/A, whereas in patients with EF>40 it is influenced only by age. RVm values showed a significant decrease in NYHA class II and III.

Transesophageal echocardiographic acquisition of mitral annulus motion during monitoring of left ventricular function in anesthetized patients

OBJECTIVE

We investigated the feasibility and reproducibility of transesophageal (TE) recordings of displacements and velocities of 4 sites of the mitral annulus in anesthetized patients. Correlations to transthoracic measures and influence of the respiratory cycle were also investigated.

METHODS

A total of 24 patients without heart disease were included. Another 10 patients were enrolled for the reproducibility study. Systolic and diastolic velocities and amplitude of motion were extracted from color-coded Doppler tissue recordings.

RESULTS

The reproducibility was not acceptable for the anterior site or for late diastolic velocities. Transthoracic values were higher than TE values. A somewhat higher displacement during inspiration in spontaneous respiration and during expiration in positive pressure ventilation was seen.

CONCLUSIONS

The anterior site should be omitted when TE recordings of the mitral annulus are used. TE values are about 15% lower than transthoracic values. There is no need to take the respiratory cycle into account.

Automated mitral annular tracking: A novel method for evaluating mitral annular motion using two-dimensional echocardiography

We developed an automated mitral annular tracking method based on a digital processing of high frame rate cineloop images of 2-dimensional echocardiography. In this study, its feasibility and accuracy was validated in 11 healthy volunteers and 16 patients with left ventricular (LV) dysfunction. The mitral annular excursion measured by automated mitral annular tracking agreed well with that measured by 3-dimensional echocardiography and correlated with LV ejection fraction. The longitudinal mitral annular excursion was reduced whereas the radial one was preserved for patients with LV dysfunction compared with control subjects. The novel automated mitral annular tracking method is clinically feasible and has potential capability to quantify the comprehensive mitral annular motion for evaluating LV function in a clinical setting.

Acute effects of smoking on diastolic function in healthy participants: studies by conventional doppler echocardiography and doppler tissue imaging

The acute effects of smoking on left ventricular (LV) function were studied in 36 healthy participants (mean age 38 +/- 10 years). The studies were made before and immediately and 30 minutes after smoking a cigarette. From apical 4- and 2-chamber views, the mitral annular velocities, determined by pulsed wave Doppler tissue imaging, were measured at 4 LV sites corresponding to the septum and the anterior, lateral, and inferior walls. A mean value from the 4 sites was used to assess LV function. The peak systolic, early diastolic, late diastolic, and the ratio of early to late diastolic velocities were recorded. In addition, other conventional Doppler echocardiographic diastolic parameters were also determined. Heart rate was increased immediately after smoking (from 67 +/- 8 to 74 +/- 10 bpm, P <.001). There was no change in systolic mitral annular velocity. Diastolic LV function was changed significantly immediately after smoking. The transmitral A wave increased (0.55 +/- 0.1 vs 0.7 +/- 0.1 m/s, P <.001), the transmitral E/A ratio decreased (1.5 +/- 0.6 vs 1.1 +/- 0.3, P <.001), and the transmitral E-wave deceleration time increased (186 +/- 42 vs 211 +/- 44 ms, P <.05). The diastolic myocardial velocity at the mitral annulus also changed significantly: the early diastolic velocity decreased (16 +/- 3 vs 15 +/- 3 cm/s, P <.001), the late diastolic velocity increased (10.9 +/- 2.2 vs 12 +/- 2.4 cm/s, P <.001), and the ratio of early to late diastolic annular velocities decreased (1.5 +/- 0.5 vs 1.2 +/- 0.4, P <.001). The changes in the transmitral flow velocities remained unaltered even 30 minutes afterward, although the heart rate returned to normal. The results were similar in both smokers and nonsmokers. Acute smoking of a cigarette influences LV diastolic function in healthy participants. The mechanism behind this effect cannot be explained only by changes in the heart rate or loading conditions. The mechanism is probably more complex.

Early systolic mitral annular motion velocities responses to dobutamine infusion predict myocardial viability in patients with previous myocardial infarction

OBJECTIVE

This study was undertaken for the determination of the correlation between myocardial viability and regional systolic mitral annular motion velocity (MAV) response to dobutamine stress in patients with previous myocardial infarction (MI) with pulsed tissue Doppler scan imaging.

METHODS

The study included 45 patients (mean age, 65 +/- 12 years) with previous MI with 1 major coronary lesion and 30 healthy individuals (mean age, 61 +/- 14 years). 99mTc-methoxyisobutylisonitrile scintigraphy was performed to divide the patients into 2 groups: the viability (+) group (n = 25) and the viability (-) group (n = 20). Dobutamine was infused (at 2, 5, 10, and 20 microg/kg/min), and the peak first and second systolic MAVs (Sw1 and Sw2, respectively) were measured at the level of the mitral annulus corresponding to the infarct regions in the MI group and to the 6 mitral annular sites in the control group. In addition, the left ventricular wall motion score index (WMSI) was determined with 2-dimensional echocardiography.

RESULTS

At baseline, the WMSI was significantly greater and the mean Sw1 and Sw2 were significantly lower in both the viability (+) and (-) groups than in the control group, but there were no significant differences between the viability (+) and (-) groups. After dobutamine infusion, the WMSI improved only in the viability (+) group. The mean Sw1 and Sw2 increased significantly with 2 microg/kg/min and 5 microg/kg/min of dobutamine, respectively, in the viability (+) group. With an increase in Sw1 of 2.0 cm/s or more with 5 microg/kg/min of dobutamine, viable myocardium was detected, with a sensitivity of 92% and a specificity of 90%. There were no significant increases in Sw1 or Sw2 in the viability (-) group with dobutamine infusion.

CONCLUSION

Viable left ventricular myocardium is identified with peak early systolic MAV during dobutamine infusion.

"Diastolic heart failure" or heart failure caused by subtle left ventricular systolic dysfunction?

OBJECTIVES

To determine whether patients with suspected heart failure but preserved systolic function, as determined by conventional echocardiographic measures (often said to have "diastolic heart failure), might have subtle left ventricular systolic dysfunction detectable by a new measure of left ventricular systolic function-left ventricular systolic atrioventricular plane displacement.

DESIGN

Observational study.

SETTING

Direct access echocardiography.

PATIENTS

147 patients with suspected heart failure referred by general practitioners.

MEASUREMENTS

Echocardiographic assessment of conventional measures of left ventricular systolic function (fractional shortening, ejection fraction (by Simpson's biplane method) and "eyeball" assessment) and measurement of left ventricular systolic atrioventricular plane displacement.

RESULTS

Between 21% and 33% of patients with "normal" left ventricular systolic function by conventional methods were found to have abnormal left ventricular systolic atrioventricular plane displacement.

CONCLUSIONS

Approximately one quarter of patients with suspected heart failure but preserved systolic function by conventional methods have abnormal atrioventricular plane displacement. These patients with suspected heart failure but preserved systolic function by conventional echocardiographic measures may have heart failure caused by subtle systolic dysfunction rather than isolated "diastolic heart failure".

Atrioventricular plane motion during dobutamine-atropine stress echocardiography: the biphasic response in healthy subjects revisited

This study was undertaken to establish normal values for the systolic atrioventricular plane motion (AVPM) from base to apex during dobutamine-atropine stress echocardiography (DASE) and to compare them with those of patients with coronary artery disease. The AVPM was measured at baseline, low dose and peak dobutamine-atropine infusion in 20 patients referred for coronary angiography and in 20 control subjects. Atrioventricular plane motion was measured at the posterior, anterior, septal, and lateral positions of the mitral annulus in the apical 2- and 4-chamber views by an observer blinded to clinical and angiographic data. In healthy subjects undergoing DASE, AVPM initially increased but subsequently decreased to below baseline values at peak stress. Atrioventricular plane motion at any stage and the changes therein during DASE were within the normal reference interval in the majority of patients. In conclusion, AVPM decreased during DASE in healthy subjects and was not a sensitive marker of coronary artery disease.

Influence of body size and age on maximal systolic velocity of mitral annulus motion

The maximal systolic velocity of the mitral annulus motion (or maximal systolic long-axis contraction velocity of the ventricle, MLACV) has been suggested as a means to assess left ventricular function. However, reference values for a wide range of age and body size are lacking. The maximal systolic velocity was studied with M-mode echocardiography using the apical four- and two-chamber views. Data are reported as the average of the measurements of four sites of the mitral annulus. Fifty-seven healthy subjects aged 6 months to 72 years were studied. In children and adolescents up to age 18, MLACV had a significant positive correlation with age, height, body surface area, weight and mitral annulus motion amplitude and a significant negative correlation with heart rate. In adults, there was a significant positive correlation between MLACV and height, mitral annulus motion amplitude and body surface area and a significant negative correlation with age and heart rate. Multiple stepwise analysis showed that the maximal systolic velocity is highly dependent on height and age in children and adolescents up to age 18, and on height in adults. The maximal long-axis contraction velocity (MLACV) can be described by the following equations: MLACV (mm s-1) = 24.0 + 0.34 x height (cm) (Standard Error of the Estimate (SEE)=10.5) in children and adolescents, and MLACV (mm s-1) = -50.5 + 0.75 x height (cm) (SEE=9.8) in adults over 18. There were significant differences between the four sites, with the highest velocity at the lateral site and the lowest velocity at the septal site. No significant difference was found between inspiratory and expiratory beats.

Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave doppler tissue imaging

This study was undertaken to assess the effect of a first myocardial infarction (MI) on the systolic and diastolic velocity profiles of the mitral annulus determined by pulsed wave Doppler tissue imaging and thereby evaluate left ventricular (LV) function after MI. Seventy-eight patients with a first MI were examined before discharge. Peak systolic, peak early diastolic, and peak late diastolic velocities were recorded at 4 different sites on the mitral annulus corresponding to the septum, anterior, lateral, and inferior sites of the left ventricle. In addition, the amplitude of mitral annular motion at the 4 above LV sites, the ejection fraction, and conventional Doppler diastolic parameters were recorded. Nineteen age-matched healthy subjects served as controls. Compared with healthy subjects, the MI patients had a significantly reduced peak systolic velocity at the mitral annulus, especially at the infarction sites. A relatively good linear correlation was found between the ejection fraction and the mean systolic velocity from the 4 LV sites (r = 0.74, P <.001). The correlation was also good when the mean peak systolic mitral annular velocity was tested against the magnitude of the mean mitral annular motion (r = 0.77, P <.001). When the patients were divided into 2 different groups with respect to an ejection fraction > or =0.50 or <0.50, a cutoff point of mean systolic mitral annular velocity of > or =7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting a preserved global LV systolic function. Similar to systolic velocities, the early diastolic velocity was also reduced, especially at the infarction sites. The peak mitral annular early diastolic velocity correlated well with both LV ejection fraction (r =.66, P <.001) and mean systolic mitral annular motion (r = 0.68, P <.001). However, no correlation existed between the early diastolic velocity and conventional diastolic Doppler parameters. The reduced peak systolic mitral annular velocity seems to be an expression of regionally reduced systolic function. The peak early diastolic velocity is also reduced, especially at the infarction sites, and reflects regional diastolic dysfunction. Thus, quantification of myocardial velocity by Doppler tissue imaging opens up a new possibility of assessing LV function along its long axis.

The relation between mitral annulus motion and left ventricular ejection fraction in atrial fibrillation

Mitral annulus motion (MAM) has recently been introduced as an index of left ventricular function. Previous studies have shown a good agreement between MAM (mm) x 5 and ejection fraction in middle-aged and elderly patients. These studies only included patients with sinus rhythm, while patients with atrial fibrillation were excluded. In the present study, MAM was reduced in patients with atrial fibrillation while ejection fraction (EF) did not differ from age-matched control patients with sinus rhythm. The 'conversion factor' (EF/MAM) was 7.2 in the group with atrial fibrillation and 5. 1 in controls with sinus rhythm. This difference must be taken into account when MAM is used to estimate left ventricular function in patients with atrial fibrillation. Patients with atrial fibrillation had lower stroke volume and higher heart rate than patients with sinus rhythm. A decreased systolic long-axis shortening was found (P<0.005) compared to patients with sinus rhythm, but no difference in short-axis diameter shortening.

Echocardiographic assessment of ejection fraction in left ventricular hypertrophy

OBJECTIVE

To investigate the value of Simpson's rule, Teichholz's formula, and recording of mitral ring motion in assessing left ventricular ejection fraction (EF) in patients with left ventricular hypertrophy.

DESIGN

Left ventricular ejection fraction calculated by Simpson's rule and by Techholz's formula and estimated by mitral ring motion was compared with values obtained by radionuclide angiography.

SETTING

Secondary referral centre.

PATIENTS

16 patients with left ventricular hypertrophy and a clinical diagnosis of hypertrophic cardiomyopathy or hypertension.

RESULTS

Calculation by Teichholz's formula overestimated left ventricular ejection fraction by 10% (p = 0.002) and estimation based on mitral ring motion-that is, long axis measurements-underestimated ejection fraction by 19% (p = 0.002), without significant correlation between ring motion and ejection fraction. There was no significant difference between mean values of ejection fraction calculated by Simpson's rule and measured by the reference method, but a considerable scatter about the regression line with a standard error of the estimate of 9.3 EF%.

CONCLUSIONS

In patients with left ventricular hypertrophy the ejection fraction, calculated by Teichholz's formula or Simpson's rule, is a poor measure of left ventricular function. When mitral ring motion is used for the assessment in these patients the function should be expressed in ways other than by the ejection fraction.

Left atrioventricular plane displacement at rest is reduced in relation to severity of coronary artery disease irrespective of prior myocardial infarction

OBJECTIVE

To examine whether left atrioventricular plane displacement (AVPD) at rest was related to severity of coronary atherosclerosis.

DESIGN AND PATIENTS

Global and regional left AVPD was evaluated by echocardiography in 159 consecutive patients with significant stenoses at coronary angiography and in 15 age-matched healthy controls. The setting was the University hospital with a primary catchment area of 250,000 inhabitants.

RESULTS

Mean AVPD in controls, patients with one-, two-, and three-vessel disease was 13.5+/-1.1, 12.4+/-1.5, 11.3+/-2.2 and 10.9+/-2.1 mm, respectively (P<0.0001). Similar significant differences were found both in those with (n=69) and without (n=90) a diagnosis of prior myocardial infarction. Regional AVPD did not correspond to the localization of infarction or coronary atherosclerosis.

CONCLUSION

Irrespective of a diagnosis of prior myocardial infarction, left AVPD was related to the degree and extent of coronary artery disease. It was significantly decreased compared to controls in patients with one-vessel disease, and was further decreased with increasing extent of coronary atherosclerosis. Determination of regional left AVPD could not be used to identify regions perfused by stenotic coronary arteries or regions affected by prior myocardial infarction.

Pulsed tissue Doppler evaluation of mitral annulus motion: a new window to assessment of diastolic function

Diastolic dysfunction is an important cause of cardiac heart failure. To date detailed assessment of diastolic left ventricular (LV) function has required invasive methods which are impractical in the clinical routine. The prevailing non-invasive method has been Doppler echocardiography with use of mitral inflow and pulmonary vein inflow parameters, measurements providing no direct assessment of either ventricular relaxation or compliance, and influenced by multiple haemodynamic factors. We sought to determine the tissue Doppler pattern from the mitral annulus motion in normals and in patients with expected LV-diastolic dysfunction. Using pulsed tissue Doppler we recorded peak velocities from the mitral annulus motion in 16 young normals, 10 older normals and in two groups of patients expected to have an LV-diastolic relaxation abnormality, i.e. 15 patients with systemic hypertension and 10 patients with significant aortic stenosis. The peak early diastolic (E) annulus velocity was significantly (P < 0.001) lower in older normals compared with young, and the late diastolic velocity (A) was higher (P < 0.01). Compared with the older normals, patients showed significantly lower E-velocities (P < 0.05 hypertensive patients), more pronounced in the patients with aortic stenosis (P < 0.001), but the A-velocities were not higher. In systole a decrease in peak velocity was noted with increasing age and in patients with aortic stenosis. In conclusion, pulsed tissue Doppler measurement of annulus motion seems to provide valuable and easily obtainable information about LV-diastolic function, and furthermore there is striking change in velocity pattern with increasing age which necessitates age-matched reference values.

Effects of Low-Dose Dobutamine on Displacement of the Atrioventricular Plane and Assessment of Myocardial Viability in Patients with Acute Myocardial Infarction Treated with Thrombolysis

Previous echocardiographic studies have highlighted the usefulness of atrioventricular (AV) plane displacement (the mitral annular motion) in assessing left ventricular function at rest. However, the effects of low-dose dobutamine on AV plane displacement in thrombolyzed patients with acute myocardial infarction (AMI) are unknown. Thirty-four patients with AMI treated with a thrombolytic agent and having rest wall motion abnormalities at the infarct site were studied with rest and low-dose dobutamine echocardiography before discharge. Thirty-one patients were followed up 18 months later with rest echocardiography. The systolic descent of the AV plane toward the apex at four different left ventricular sites (i.e., at the septal, anterior, lateral, and inferior walls) was recorded to assess left ventricular function. Compared with age-matched healthy subjects, the AV plane displacement was significantly reduced, especially at the infarct sites, in AMI patients at rest. During low-dose dobutamine, the AV plane displacement was increased at infarct sites (P < 0.001) in patients with signs of viability. A cutoff point of an increase in AV plane displacement of >/= 2 mm at the infarct sites during low-dose dobutamine stress had a sensitivity of 89% and a specificity of 87% in assessing myocardial viability. Using the same cutoff point of a spontaneous increase in the AV plane displacement of >/= 2 mm during the follow-up rest echocardiography, 87% of the patients with initial signs of viability and only 25% without signs of viability showed a spontaneous late recovery of initially stunned myocardium. Thus, the study shows that changes in the amplitude of the AV plane displacement during low-dose dobutamine stress echocardiography can easily be used to detect myocardial viability at an early stage with late potential spontaneous recovery.

Usefulness of coronary angiography for assessing left ventricular function

The correlation of ejection fraction to left ventricular long-axis contractions, measured from left coronary ostium to apical arterial branches, on coronary angiograms was investigated.

Reduced left ventricular relaxation velocity after acute myocardial infarction

Diastolic left ventricular function is usually described using Doppler recording of the early to atrial (E/A) ratio. However, because of pseudonormalization in patients with moderately impaired diastolic function, the E/A ratio does not allow a meaningful comparison between a group of patients with varying degrees of dysfunction, e.g. after acute myocardial infarction (AMI), and a group of healthy control subjects. In this study, diastolic function was assessed using the E/A ratio, deceleration time of early mitral inflow and maximal longitudinal relaxation velocity. The relaxation velocity was measured using echocardiographic M-mode recording of mitral annulus motion. Mitral annulus motion was recorded in four- and two-chamber views. Relaxation velocities were measured in the septal, lateral, anterior and posterior parts of the mitral annulus and the mean value (RVm) was calculated. Twenty-two consecutive patients were investigated 3-21 days after first transmural AMI. Twenty-two healthy subjects of similar age served as a control group. The group of patients with AMI had an RVm of 40.9 +/- 15.4 mm s-1 compared with 68.5 +/- 12.4 mm s-1 in the control group (P < 0.0001). In contrast, the E/A ratio, deceleration time and heart rate did not differ significantly between the two groups. The results suggest that maximal longitudinal relaxation velocity is a simple and appropriate measure of diastolic function in patients with transmural AMI.

Left Ventricular Systolic Function in a Population Sample of Elderly Men

BACKGROUND: The present study was designed to evaluate the usefulness and discriminatory power of different echocardiographic indices of left ventricular (LV) systolic function in a healthy screening sample of 584 men who were 70 years old. METHODS: Ejection fraction (EF), fractional shortening (FS), stroke index (SI), left ventricular diameter in systole (LVESD), and cardiac index (CI) were evaluated, in addition to LV wall motion score and atrioventricular plane displacement (AVPD). RESULTS: Subjects with hypertension or coronary heart disease (CHD), but not those with diabetes mellitus, showed impairments in EF, FS, LVESD, AVPD, and LV wall motion scores compared with the healthy subjects in the sample (P < 0.01-0.001). SI and CI findings in those with hypertension or CHD were, however, no different from those in the healthy group. The index of LV systolic function that discriminated best between diseased and healthy subjects was LV wall motion score, being correlated with EF, LVESD, and AVPD but only poorly with SI and CI. SI evaluated with use of the Teichholz formula was correlated to LV end-diastolic diameter (r = 0.72, P < 0.0001), whereas the corresponding correlation between SI measured with Doppler (aortic flow) and LVEDD was weak. The difference between the Teichholz and Doppler evaluations of SI was dependent on LV end-diastolic diameter (r = 0.51, P < 0.001) but not on LV systolic function. An index, the systolic two-dimensional index, which takes into account both the longitudinal motion (AVPD) and movement along the short axis (LVESD) during systole, was suggested by the formula AVPD + 5/LVESD. CONCLUSIONS: Impaired LV systolic function was found in both elderly men with hypertension and those with CHD. SI was normal in these groups, however, although overestimated when measured with the Teichholz formula in this population with a large proportion of subjects with LV dilatation. AVPD appears to be applicable in the present population, and a new systolic index consisting of LVESD and AVPD is suggested for the evaluation of LV systolic function in two dimensions.

The Contribution of the Left Atrioventricular Plane Displacement During Low Dose Dobutamine Stress Echocardiography in Predicting Recovery of Left Ventricular Dyssynergies

The aim of this study was to assess the significance of the left systolic atrioventricular (AV) plane displacement during low dose dobutamine stress echocardiography (DSE), in predicting the recovery of left ventricular dyssynergies after revascularization. In 30 infarctiers with left ventricular dysfunction scheduled for RE (14 percutaneous transluminal coronary angioplasty and 16 coronary artery bypass graft) and in 25 age- and sex-matched healthy subjects, a DSE, using a 16 ventricular segment model and a four-grade scoring system for the assessment of regional wall motion of the left ventricle was performed. Prior and during DSE, the left systolic AV plane displacement was recorded from the apical four- and two-chamber views, by M-mode echo, at four left ventricular sites, corresponding to the septal, lateral, anterior, and inferior walls, both in patients and controls. The study was repeated in all patients 101 +/- 14 days after successful revascularization. Healthy subjects showed a significant increase of left systolic AV plane displacement at all left ventricular sites during dobutamine infusion (DI) (P < 0.001). Patients also exhibited a significant maximum increase of left systolic AV plane displacement during DSE only in the dyssynergic sites with functional improvement in the postrevascularization echocardiogram (P < 0.001). In the remaining dyssynergic sites, without functional improvement after revascularization, the left systolic AV plane displacement did not change (P > 0.05). Selecting a maximum LAVPD increase of >2 mm at any site of the left ventricule to predict recovery of the regional ventricular dyssynergies, results in a sensitivity of 91%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 87%. When two-dimensional DSE was used for the detection of reversible dysfunction, sensitivity and specificity were found to be 81.5% and 87.5%, respectively, while the positive and negative predictive values were 90% and 78%, respectively. When the two methods were in agreement the sensitivity was 90%, the specificity 100%, and the positive and negative predictive values were 100% and 84.2%, respectively. The assessment of left systolic AV plane displacement during DI constitutes a new, simple, and accurate method in the prediction of left ventricular dyssynergy recovery after revascularization. The combination of this method and two-dimensional DSE are basic predictor markers of viability of dysfunctional myocardium. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Assessment of mitral annular dynamics during diastole by Doppler tissue imaging: comparison with mitral Doppler inflow in subjects without heart disease and in patients with left ventricular hypertrophy

The purpose of this study was to determine the normal pattern and magnitude of mitral annular velocities in diastole by Doppler tissue imaging (DTI) and to assess whether this is altered in patients with left ventricular hypertrophy. Mitral annulus velocities were measured by DTI. Peak and time-velocity integral were measured from the DTI tracings and the timing of the velocities in relation to electrocardiogram. DTI was compared with M-mode echo of the annulus and mitral inflow Doppler velocities. Integrated annular velocities by DTI correlated with the annular displacement. Early diastolic velocities decreased with age and in patients with left ventricular hypertrophy. In the hypertrophy group, early diastolic velocities were significantly lower than normal even after correcting for age. Patients with left ventricular hypertrophy also showed a delay in peak early diastolic mitral annular velocity (5.5 +/- 21 msec after the E wave). In conclusion, mitral annular velocity in diastole is readily recorded by DTI. The magnitude and the pattern of these velocities are significantly altered by age and by left ventricular hypertrophy. This method provides a new insight into diastolic filling events and may prove useful in detecting abnormal diastolic function.

Systolic excursion of the mitral annulus to assess septal function in paradoxic septal motion

To determine whether mitral valve annulus displacement (MVAD) can be used to assess septal contractility in patients with paradoxical septal motion, we assessed four atrioventricular regions (septum, lateral wall, anterior wall, and inferior wall) by MVAD in 80 consecutive patients. The patients were divided into five groups: group 1 (control) (n = 20), normal left ventricular (LV) systolic function; group 2 (n = 15), paradoxical septal motion resulting from left bundle branch block (LBBB) and normal segmental and global LV systolic function; group 3 (n = 19), paradoxical septal motion as a result of cardiac surgery, and normal segmental and global LV systolic function; group 4 (n = 11), paradoxical septal motion resulting from LBBB, dilated cardiomyopathy, and severely depressed LV systolic function; group 5 (n = 15), septal hypokinesis with either normal or mildly depressed global LV systolic function. In groups 1, 2, and 3, 80% to 100% of patients had septal and other regional MVAD > or = 1.0 cm. The average MVAD in group 4 (dilated cardiomyopathy), was significantly decreased ( < or = 0.8 cm) in all four regions (p < 0.01 compared with groups 1, 2, and 3). In group 5 (septal hypokinesis), the septal MVAD was > or = 1.0 cm in only 13% of the patients (p < 0.025 compared with groups 1, 2, and 3). In conclusion, patients with paradoxical septal motion caused by LBBB or cardiac surgery have preserved septal contractility when evaluated by MVAD.

Significance of echocardiographic atrioventricular plane displacement for the evaluation of left ventricular filling and end-diastolic pressure in patients with coronary artery disease

The aim of this study is to assess the left ventricular filling and estimate the end-diastolic pressure of the left ventricle in patients with coronary artery disease (CAD) by echocardiographic measurement of the atrioventricular plane displacement (AVPD). In 101 patients (mean age 59 +/- 12 years) with CAD, a complete transthoracic echocardiographic study was performed, just prior to cardiac catheterization. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views. The recordings were obtained at four sites, corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. The mean AVPD resulting from atrial systole (At), the mean total (T) diastolic AVPD, the ratio At/T(%) and the ratio of mitral annulus excursion during early and late diastole [(T-At)/At] were calculated. Firty-two age-matched healthy subjects served as control group. Both At and At/T were significantly greater in patients with CAD than in the controls (6.06 +/- 0.94 vs 5.53 +/- 0.55 mm, p < 0.01 and 43.4 +/- 5.9% vs 33.49 +/- 4.45%, p < 0.001 respectively). The ratio [(T-At)/At] correlated with the E/A ratio of transmitral flow, both in healthy subjects (r = 0.850, p < 0.001) and in patients with CAD (r = 0.722, p < 0.001). Correlation also existed both in patients with segmental wall motion abnormality (SWMA) (r = 0.691, p < 0.001) and in patients with SWMA (r = 0.818, p < 0.001). In patients with CAD, At/T further correlated with the left ventricular end-diastolic pressure (r = 0.517, p < 0.001). In patients with SWMA and in patients without, a correlation was also found (r = 0.516, p < 0.001 and r = 0.566, p < 0.001 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

A new echocardiographic formula to calculate ejection fraction by using systolic excursion of mitral annulus

The correlation between echocardiographically and angiographically calculated ejection fraction and systolic excursion of the mitral annulus was studied in 81 patients. Knowing that the mitral annulus changes its size, shape, and position during the cardiac cycle, the authors measured systolic excursion of the annulus by 2D echocardiography. Displacement of the mitral annulus was measured from four different points (medial, lateral, anterior, posterior) by apical four-chamber and apical two-chamber approaches. Patients with and without regional wall motion abnormalities were included. Left ventricular volumes and ejection fraction (EF) were calculated in the standard manner introduced by Teichholz et al and also with biplane left ventriculography. As a result, EF calculated by cineangiography, was moderately correlated with the Teichholz method (r = 0.66) while it was highly correlated with measurements of mitral annular motion (MAM) (r = 0.87). The correlation can be expressed by the regression equation, EF (angiography) = 5.7 MAM (in mm) -6.5. They conclude that measurements of annular motion is an easy and reliable index of left ventricular function as an alternative to traditional methods.

Evaluation of left ventricular filling by echocardiographic atrioventricular plane displacement in patients with coronary artery disease

Mean atrioventricular (AV) plane displacement which resulted from left atrial systole and its ratio to the total diastolic displacement, were determined by echocardiography in 101 patients with coronary artery disease. Ratio of motion of the AV plane caused by left atrial systole to the total diastolic displacement was correlated with late-to-early mitral flow peak velocity index (r = 0.7). Selecting a value of this ratio of the AV plane displacement > or = 44% to define Doppler characteristics indicating impaired left ventricular relaxation, resulted in a high sensitivity, specificity and predictive value. Its value was also validated in another prospectively examined group of coronary artery disease patients. In conclusion echocardiographic assessment of AV plane displacement can be used for the estimation of left ventricular filling in patients with coronary artery disease and particularly in detecting impaired left ventricular relaxation.

Mitral regurgitation following first-time acute myocardial infarction--early and late findings by Doppler echocardiography

A total of 61 patients with first-time mild to moderate acute myocardial infarction and no reinfarction within the following 2 months were studied prospectively by Doppler echocardiography before hospital discharge and after 2 months to evaluate the prevalence of mitral regurgitation. Twenty-one age-matched healthy subjects served as controls. At baseline, the prevalence of Doppler-recorded mitral regurgitation was 74% and 29% in patients and controls, respectively. In the patients, the regurgitant flow measured by color flow Doppler was 1.04 cm2 (range 0.2-8 cm2) and occupied 7.5% (range 2-45%) of the left atrial area. Corresponding figures for controls were 0.35 cm2 (0.1-0.6) and 2.4% (0.7-4.5), respectively. On continuous wave Doppler, most patients (33/45) had Doppler signals similar to those of healthy controls. The prevalence of mitral regurgitation was about the same in anterior and inferior infarction (75 and 72% respectively). In the patients, the prevalence was similar after 2 months (79%) with minor changes in the Doppler characteristics of the regurgitation (regurgitant flow 1.12 cm2 and occupying 8.1% of left atrial area). The study demonstrates that in a group of patients with first-time mild to moderate myocardial infarction the prevalence of Doppler-recorded mitral regurgitation is high and mild in severity in the majority of the cases. The changes remain almost similar even after 2 months.

Longitudinal systolic shortening of the left ventricle: an echocardiographic study in subjects with and without preserved global function

The atrioventricular (AV) plane displacement was studied by echocardiography in 79 subjects (45 healthy subjects and 34 patients with acute myocardial infarction or chronic congestive heart failure). From apical 4- and 2-chamber views the displacement of the AV plane towards the apex in systole was recorded at 4 sites in the left ventricle (LV) corresponding to the septal, anterior, lateral, and posterior walls and the mean value from the above 4 sites (AV-mean) was calculated. In addition, in healthy subjects, the AV plane displacement at right ventricular free wall was also recorded. The AV-mean correlated well with the echocardiographic ejection fraction determined by biplane area-length method (r = 0.96, P less than 0.001). The correlation was also high when the percentage of the left ventricular shortening along the long axis was used (r = 0.97, P less than 0.001). The correlation between ejection fraction and AV-mean was also good when separate analysis was made for the subjects with preserved ejection fraction (r = 0.86, P less than 0.001) and decreased ejection fraction (r = 0.82, P less than 0.001). The right ventricle had a significantly higher AV plane displacement (P less than 0.001) than the LV. The study also includes determination of the muscular excursions of the septal and posterior walls along the short axis of the left ventricle from the parasternal long axis view. The AV plane displacement of the respective walls was relatively greater (P less than 0.001) compared to concentric contractions. The septal and posterior wall excursions along the short axis correlated poorly with the AV plane displacement of the respective walls (r = 0.55, P less than 0.01 and r = 42, P less than 0.05).

Serial echocardiographic studies following thrombolytic treatment in myocardial infarction with special reference to the atrioventricular valve plane displacement

Echocardiographic recording of the atrioventricular (AV) valve plane displacement was used for serial studies of left ventricular (LV) function in 27 patients with first-time acute myocardial infarction (MI) treated with a thrombolytic agent within 4 h of the onset of symptoms and showing noninvasive signs of early reperfusion. The recordings were made immediately before or during thrombolytic therapy and 24 h, 1 week, 1 month, and 2 months after attempted reperfusion. Regional LV function was assessed by recording the amplitude of systolic descent of the AV plane toward the apex at 4 different sites on left ventricle corresponding to the septal, anterior, lateral, and posterior walls from apical 4- and 2-chamber views. Global LV function was assessed using the mean value of the AV plane displacement from the above 4 sites (AV mean). In 15 patients with anterior MI, the displacement at the septum and anterior wall was significantly decreased compared with the posterior and lateral walls at baseline. The displacement had increased significantly after 1 week, 1 month, and 2 months (p less than 0.01, p less than 0.01, and p less than 0.001). The AV mean also increased significantly (p less than 0.01) during the study period. A corresponding regional increase was observed in inferior MI. The AV mean remained unchanged, however, during the follow-up period. It is concluded that the easy visualization and the simplicity of recording the AV plane displacement makes the method a valuable non-invasive tool for serial echocardiographic studies following acute MI treated with a thrombolytic agent.

Abnormal right heart filling after cardiac surgery: time course and mechanisms

OBJECTIVE

To study the time course and underlying mechanisms of right heart filling after cardiac surgery.

DESIGN

A prospective observational study of adult patients undergoing cardiac surgery.

SETTING

Echocardiography laboratory of the Stanford University Medical Center.

PATIENTS

Twenty six patients (mean age 54.9) undergoing cardiac surgery were studied before and two days, one week, six weeks, and six months after cardiac surgery.

MAIN OUTCOME MEASURES

Flow in the hepatic veins and superior vena cava, tricuspid and mitral annulus motion, signs of tricuspid regurgitation, and right ventricular size were assessed by echocardiography.

RESULTS

Right heart filling, expressed as the ratio of systolic to diastolic forward flow Doppler velocity integrals in the superior vena cava and by tricuspid annulus motion, decreased in parallel from before surgery baseline values of 3.5 (SD 3.1) and 21.9 (3.4) mm, respectively to 0.2 (0.1) and 8.1 (2.3) mm two days after operation. A gradual increase towards baseline values was noted after six months, to 1.4 (1.3) and 15.1 (2.3) mm respectively; however, these values were still significantly less than those before operation. Similar changes were seen in the hepatic venous flow pattern. The decrease in total tricuspid annulus motion was most pronounced in its lateral segment and the atrial component of the tricuspid annulus motion showed similar changes.

CONCLUSIONS

The pronounced decrease in tricuspid annulus motion during the early postoperative period suggests right atrial and right ventricular dysfunction as mechanisms responsible for the early changes seen. The progressive return to a normal venous filling pattern and the partial recovery of annular motion six months after operation further support the influence of the above mechanisms, as well as their resolution with time. The persistent flow abnormalities and compromised motion of the free aspects of the tricuspid annulus, however, suggest long term tethering of the right heart wall.