Tissue Doppler to Assess Diastolic Left Ventricular Function

[Assessment of Left Ventricular Diastolic Function Using ECG-gated Myocardial Perfusion SPECT in Small Heart: Comparison with Ultrasound Echocardiography]

BACKGROUND

Assessment of left ventricular (LV) diastolic function is important because it is possible to detect early sign of myocardial ischemia by this assessment. The purpose of this study was to compare between electrocardiogram (ECG) -gated myocardial perfusion single photon emission computed tomography (G-SPECT) and ultrasound echocardiography in assessment of LV diastolic function in the small heart (SH).

METHODS

The study population consisted of 144 patients who underwent both G-SPECT and ultrasound echocardiography. Peak filling rate (PFR), one-third mean filling rate (1/3 MFR) and the ratio of time to PFR to the RR interval (TPFR/RR) were calculated by quantitative gated SPECT (QGS) and heart risk view-F (HRV-F). Peak early mitral annular velocity (e') was used as the reference standard of LV diastolic function.

RESULTS

There were 33 patients with end-systolic volume (ESV) of ≤10 ml (SH10), 51 patients with ESV of 11-20 ml (SH 20) and 60 patients with ESV of >20 ml (normal-sized heart: NH). In SH10, PFR calculated by QGS was not correlated with e'. However, that by HRV-F was significantly correlated with e' (r=0.47, p=0.006). On the other hand, 1/3 MFR and TPFR/RR calculated by QGS and HRV-F were not correlated with e' in SH10 and SH20. PFR, 1/3 MFR and TPFR/RR calculated by QGS and HRV-F were correlated with e' in NH.

Influence of dynamic obstruction and hypertrophy location on diastolic function in hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a disease with marked genetic and phenotypic heterogeneity. It is well known that obstructive septal forms of this disease entail worse clinical outcome compared with nonobstructive septal and apical forms. The objective of this study was to analyze the differences in left ventricular diastolic function in different subgroups of HCMs and to assess the influence of the location of myocardial hypertrophy and the presence of dynamic obstruction on impairment of diastolic function and its correlation with the clinical status.

METHODS

We studied 86 patients with HCM; 27 with the obstructive asymmetric septal type (OAS), 37 with the nonobstructive asymmetric septal type (NOAS) and 22 with apical hypertrophic cardiomyopathy (ApHCM). Patients underwent conventional and tissue Doppler echocardiography and were assessed applying the latest recommendations regarding diastolic dysfunction. Cardiac magnetic resonance was used to study the various morphologic subtypes and quantify left ventricular mass (LVM).

RESULTS

The early diastolic annular velocity (e') was significantly lower in OAS with a median of 5 cm/s compared with NOAS with 7 cm/s and ApHCM with 7.5 cm/s (P = 0.0002), and the E/e' ratio was 8.5 in ApHCM, 10 in NOAS and 14 in OAS (P = 0.0001); no significant differences were found in LVM or maximal wall thickness.

CONCLUSION

In HCM, the location of left ventricular hypertrophy and the presence of dynamic obstruction affect the degree of diastolic dysfunction; impairment is greater in patients with the OAS type, and markedly less in patients with apical involvement.

Biomarker and imaging responses to spironolactone in subclinical diabetic cardiomyopathy

BACKGROUND

Subclinical diabetic cardiomyopathy (DCM) is frequent in asymptomatic subjects with type 2 diabetes (T2DM). We sought the response of functional and fibrosis markers to therapy in a trial of aldosterone antagonism for treatment of DCM.

METHODS

Biochemical, anthropometric, and echocardiographic data were measured in 225 subjects with T2DM. Myocardial function was evaluated with standard echocardiography and myocardial deformation; ischaemia was excluded by exercise echocardiography. Calibrated integrated backscatter and post-contrast T1 mapping from cardiac magnetic resonance imaging were used to assess myocardial structure. Amino-terminal propeptides of pro-collagen type I (PINP) and III (PIIINP), the carboxy-terminal propeptide of pro-collagen type I (PICP) and transforming growth factor beta-1 were measured from peripheral blood or urine to assess myocardial collagen turnover.

RESULTS

Diastolic dysfunction was identified in 81 individuals, of whom 49 (25 male, age 60 ± 10 years) were randomized to spironolactone 25 mg/day or placebo therapy for 6 months. Groups were well-matched at baseline. Spironolactone therapy was associated with improvements in diastolic filling profile (Δpeak E wave velocity -4 ± 15 vs. 9 ± 10 ms, P = 0.001; ΔE/A ratio -0.1 ± 0.3 vs. 0.2 ± 0.2, P < 0.001) and cIB values (-21.2 ± 4.5 dB vs. -18.0 ± 5.2 dB, P = 0.026; ΔcIB -5.1 ± 6.8 vs. -1.3 ± 5.2, P = 0.030). ΔcIB was independently associated with spironolactone therapy (β = 0.320, P = 0.026) but not Δblood pressure. With intervention, pro-collagen biomarkers (ΔPINP P = 0.92, ΔPICP P = 0.25, ΔPIIINP P = 0.52, and ΔTGF-β1 P = 0.71) and T1 values (P = 0.54) remained similar between groups.

CONCLUSIONS

Spironolactone-induced changes in myocardial structure and diastolic properties in DCM are small, and are unassociated with changes in collagen biomarkers or T1 values.

Perioperative Diastolic Dysfunction

Left ventricular diastolic dysfunction (LVDD) has only recently been recognized as an important determinant of perioperative morbidity. Intraoperative echocardiographers have been slow to adopt assessment of LVDD into clinical practice. This has been partly attributable to the complex measurements required to characterize LVDD, which are in turn related to how our understanding of diastole has evolved. Additionally, the lack of effective therapeutic options has left many wondering whether it is worthwhile to characterize this pathology in the first place. However, therapies are developed more rapidly once a problem can be identified reliably. The assessment of LVDD is centered on how effectively the left ventricle can fill. Diastolic dysfunction affects intraventricular pressures and stiffness, which in turn affect the pressure relationship between the left atrium and the left ventricle thereby affecting transmitral flow. Since echocardiography can enable the measurement of flow velocities, transmitral diastolic filling flow patterns provide robust information on diastolic function. The impact of abnormal diastolic function on left atrial pressure has consequences for pulmonary venous flow, which can also be measured with echocardiography. However, given the limitations of flow velocity, direct measurement of tissue velocity can significantly improve the characterization of diastolic dysfunction. The evolution of Doppler and speckle-based methods of assessing tissue motion have vastly improved our understanding of diastolic function. With the development of simpler algorithms for categorization, and their gradual adoption by perioperative echocardiographers, LVDD should be better diagnosed and treated to improve postoperative outcomes.

Noninvasive evaluation of left ventricular noncompaction: what's new in 2009?

Significant interest in clinical practice as well as the medical literature exists regarding the presentation and outcome of children and adults with left-ventricular noncompaction (LVNC). The mainstay in the diagnosis of LVNC has been the anatomic definition of the ventricular myocardium by two-dimensional echocardiographic imaging. Although helpful, this approach lacks diagnostic precision and fails to evaluate the functional impact of this abnormal myocardial architecture on global and regional myocardial performance. This review will focus on the use of novel echocardiographic modalities of tissue Doppler, strain, and strain rate imaging to identify and characterize abnormalities of regional myocardial function in patients with LVNC.

Feline myocardial disease 2: diagnosis, prognosis and clinical management

Clinical challenges The diagnosis, prognosis and clinical management of feline myocardial disease (cardiomyopathy, CM) represent controversial areas in veterinaty cardiology. Diagnosis is challenging primarily because of the complex classification of feline CM, which is based on a variety of structural and functional phenotypes. Similarly, prognosis is strongly dependent on the underlying aetiology and stage of the disease, which are often unrecognised. These challenges underline the importance of a thonaugh clinical evaluation of the patient and understanding of the underlying pathophysiological mechanisms in order to select the most appropriate treatment and provide the highest standards of care.

Patient group Although a genetic predisposition has been demonstrated in some feline pedigrees (ie, Maine Coons, Ragdolls), CM can potentially affect all breeds and different age groups.

Audience General practitioners, as well as specialists in small animal medicine, cardiology and pathology, deal with feline CM cases on a regular basis.

Diagnostics Diagnosis of feline CM is primarily based on echocardiographic examination. However, even the most sophisticated techniques present important limitations because they do not necessarily identify the primary cause of the disease or recognise the precise origin of an end-stage myocardial disease. Thoracic radiography remains one of the most useful tools for identifying changes consistent with congestive heart failure. Novel diagnostic techniques include cardiac magnetic resonance imaging, positron emission tomography and genetic tests.

Evidence base Although knowledge of feline CM remains fairly rudimentary, important discoveries have been made in the past few years. Evidence-based studies have significantly improved understanding of genetic predisposition, biomarkers and response to pharmacological treatments. Hopefully, many of the unsolved questions raised in this article will find a definitive answer in the near future.

New options in noninvasive assessment of left ventricular torsion

The complex, intricate 3D pattern of ventricular torsion has both fascinated and perplexed scientists for centuries. The identity of the underlying anatomic myocardial unit responsible for this pattern of contraction continues to be an arena of debate. While the complicated wringing motions involved in torsion are difficult to quantify, several techniques have been demonstrated to be effective in the noninvasive assessment of left ventricular (LV) torsion. Magnetic resonance tissue-tagging with dynamic MRI is the gold standard for the noninvasive quantitative evaluation of torsion with high spatial and temporal resolution. However, this is a technically involved and potentially time-consuming process. Echocardiography is another alternative noninvasive method. Both tissue Doppler imaging and speckle-tracking imaging have been shown to be sufficiently accurate and reliable alternatives to MRI in the noninvasive assessment of LV torsion. While the potential applications of these techniques to assess LV torsion appears boundless, further studies are needed to validate measures of LV torsion by the additional, but most important, test of demonstrating its clinical utility as a predictor of prognosis.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changes in tissue Doppler characteristics in a patient with pulmonary atresia and intact ventricular septum

Tissue Doppler measurements of the right and left lateral ventricular walls were made before and after perforation of the pulmonary valve using radiofrequency energy in a patient with pulmonary atresia and intact ventricular septum. The ratio of peak tissue velocity during rapid ventricular filling to atrial contraction increased for both atrioventricular valves after perforation of the pulmonary valve, and the patient was able to be weaned off prostaglandins without further intervention. Such measurements made using tissue Doppler may aid in the management of patients with pulmonary atresia and intact ventricular septum by predicting improvements in right ventricular relaxation.

Relationship of diastolic intraventricular pressure gradients and aerobic capacity in patients with diastolic heart failure

We sought to elucidate the relationship between diastolic intraventricular pressure gradients (IVPG) and exercise tolerance in patients with heart failure using color M-mode Doppler. Diastolic dysfunction has been implicated as a cause of low aerobic potential in patients with heart failure. We previously validated a novel method to evaluate diastolic function that involves noninvasive measurement of IVPG using color M-mode Doppler data. Thirty-one patients with heart failure and 15 normal subjects were recruited. Echocardiograms were performed before and after metabolic treadmill stress testing. Color M-mode Doppler was used to determine the diastolic propagation velocity ( Vp) and IVPG off-line. Resting diastolic function indexes including myocardial relaxation velocity, Vp, and E/ Vp correlated well with V̇o2 max ( r = 0.8, 0.5, and −0.5, respectively, P < 0.001 for all). There was a statistically significant increase in Vp and IVPG in both groups after exercise, but the change in IVPG was higher in normal subjects compared with patients with heart failure (2.6 ± 0.8 vs. 1.1 ± 0.8 mmHg, P < 0.05). Increase in IVPG correlated with peak V̇o2 max ( r = 0.8, P < 0.001) and was the strongest predictor of exercise capacity. Myocardial relaxation is an important determinant of exercise aerobic capacity. In heart failure patients, impaired myocardial relaxation is associated with reduced diastolic suction force during exercise.

[Characteristics of hypertensive cardiomyopathy in a population of hypertensive patients never treated]

BACKGROUND AND OBJECTIVE

Although impaired diastolic function is frequently found in systemic hypertension, the diagnosis of hypertensive heart disease (HHD) is based on the demonstration of left ventricular (LV) growth. The aim of the current work was to investigate the potential interactions between diastolic function and LV growth in patients with arterial hypertension.

PATIENTS AND METHOD

One hundred and sixteen never-treated asymptomatic hypertensives underwent an echocardiographic evaluation. Classification of diastolic dysfunction (DD) was based on alterations in parameters assessing transmitral inflow, Doppler tissue imaging of mitral annular motion, and color M-mode propagation velocity. Classification of LV growth was based on alterations in left ventricular mass index and/or relative will thickness.

RESULTS

Ninety-four patients (81%) exhibited DD and 22 (19%) exhibited normal diastolic function. Amongst patients with DD, 79 (84%) exhibited a pattern of impaired relaxation and 15 (16%) a pseudonormal pattern. The presence of LV growth was documented in 41% of patients without DD and 75% of patients with DD (p < 0.05). None of the studied patients exhibited echocardiographic signs of systolic dysfunction.

CONCLUSIONS

These findings indicate that DD is an early and highly frequent cardiac alteration in arterial hypertension. In addition, our data show that one fifth of hypertensive patients have DD in the absence of LV growth. It is thus suggested that the diagnosis of HHD can not be further based exclusively on morphologic criteria and should include also the evaluation of alterations in LV filling.

Assessment of Left Ventricular Torsional Deformation by Doppler Tissue Imaging

Background— Left ventricular (LV) torsional deformation is a sensitive index for LV performance but difficult to measure. The present study tested the accuracy of a novel method that uses Doppler tissue imaging (DTI) for quantifying LV torsion in humans with tagged magnetic resonance imaging (MRI) as a reference.

Methods and Results— Twenty patients underwent DTI and tagged MRI studies. Images of the LV were acquired at apical and basal short-axis levels to assess LV torsion. We calculated LV rotation by integrating the rotational velocity, determined from DTI velocities of the septal and lateral regions, and correcting for the LV radius over time. LV torsion was defined as the difference in LV rotation between the 2 levels. DTI rotational and torsional profiles throughout systole and diastole were compared with those by tagged MRI at isochronal points. Rotation and torsion by DTI were closely correlated with tagged MRI results during systole and early diastole (apical and basal rotation, r =0.87 and 0.90, respectively; for torsion, 0.84; P <0.0001, by repeated-measures regression models). Maximal torsion showed even better correlation ( r =0.95, P <0.0001).

Conclusions— The present study has shown that DTI can quantify LV torsional deformation over time. This novel method may facilitate noninvasive quantification of LV torsion in clinical and research settings.

Myocardial Tissue Velocities in the Normal Left and Right Ventricle: Relationships and Predictors

OBJECTIVES

(1) To document, using tissue Doppler echocardiography (TDE), the regional variations in myocardial velocities (MV) in the left and right ventricles (LV and RV) in healthy young adults. (2) To determine the factors predicting MV.

BACKGROUND

The pattern of tissue velocities within the right ventricle have yet to be determined and their patterns compared to the left ventricular velocities have not yet been described.

METHODS

Forty healthy subjects, mean age 29+/-6 years, were studied using TDE. Left ventricular long-axis velocities (V(LV-LX)) were obtained by sampling from anteroseptal, anterior, lateral, posterior, inferior and inferoseptal LV walls, and long-axis RV velocities (V(RV-LX)) from the free wall of the RV, in standard apical views. LV radial velocities (V(LV-RAD)) and RV radial velocities (V(RV-RAD)) were assessed from the parasternal long and short-axis views. Regression analyses were performed to assess for correlations of MV with the variables: age, sex, QRS duration, heart rate, systolic and diastolic blood pressure, LV mass, width, LV or RV lengths, LA or RA areas.

RESULTS

There were marked but consistent regional variations in systolic and diastolic tissue velocities in the LV and RV. Systolic (S') and early diastolic (E') velocities differed significantly around the left ventricular base, the highest velocities being located within the free wall at 6.4+/-2.2cm/s and 11.3+/-3.1cm/s, respectively. The E'/S'ratio remained constant and independent of position. V(LV-LX) were significantly higher than V(LV-RAD) (p<0.001). V(LV-LX)S' velocities were consistently lower than V(RV-LX)S' velocities (p<0.001). Age, heart rate, LV mass, width and length were significantly and independently associated with V(LV-LX)S' and V(LV-LX)E' values (p<0.01 for each).

CONCLUSIONS

In healthy young adults, there is a consistent pattern of non-uniform MV throughout the heart, including differences in longitudinal and radial axis velocities both within the LV and between the LV and RV. Age, heart rate and LV structure are important determinants of MV.

CONDENSED ABSTRACT

The patterns of left and right ventricular myocardial velocities and their relationships to each other are not well characterized. Furthermore, the determinants of myocardial velocities are not known. This study evaluated the myocardial longitudinal and radial axis tissue velocities in both the left (LV) and right (RV) ventricles and found that a consistent but non-uniform relationship exists between the LV and RV in both longitudinal and radial axes. Furthermore, age, heart rate and LV dimensions account for between 20% and 70% of the variability seen in LV systolic and diastolic velocities.

Strukturierter Datensatz zur Befunddokumentation in der Echokardiographie?Version 2004

A standardized documentation of echocardiographic studies is necessary to provide comparability of data and to realize software-based documentation and electronic communication, both essential for quality management in echocardiography.Therefore, the subgroup on "Standardization and LV function" of the working group on cardiovascular ultrasound of the German Cardiac Society developed a consensus report for documentation of echocardiographic studies, which was first published in 2000. This report represents the current update of the standardized documentation for echocardiography; its impact for quality management in conjunction with the "guidelines echocardiography" is discussed.