Comparative value of tissue Doppler imaging and m-mode color Doppler mitral flow propagation velocity for the evaluation of left ventricular filling pressure

Noninvasive Evaluation of Cardiac Chamber Pressures Using Subharmonic-Aided Pressure Estimation With Definity Microbubbles

BACKGROUND

Noninvasive and accurate assessment of intracardiac pressures has remained an elusive goal of noninvasive cardiac imaging.

OBJECTIVES

The purpose of this study was to investigate if errors in intracardiac pressures obtained noninvasively using contrast microbubbles and the subharmonic-aided pressure estimation (SHAPE) technique are <5 mm Hg.

METHODS

In a nonrandomized institutional review board-approved clinical trial (NCT03243942), patients scheduled for a left-sided and/or right-sided heart catheterization procedure and providing written informed consent were included. A standard-of-care catheterization procedure was performed advancing clinically used pressure catheters into the left and/or right ventricles and/or the aorta. After pressure catheter placement, patients received an infusion of Definity microbubbles (n = 56; 2 vials diluted in 50 mL of saline; infusion rate: 4-10 mL/min) (Lantheus Medical Imaging). Then SHAPE data was acquired using a validated interface developed on a SonixTablet scanner (BK Medical Systems) synchronously with the pressure catheter data. A conversion factor (mm Hg/dB) was derived from SHAPE data and measurements with a SphygmoCor XCEL PWA device (ATCOR Medical) and was combined with SHAPE data from the left and/or the right ventricles to obtain clinically relevant systolic and diastolic ventricular pressures.

RESULTS

The mean value of absolute errors for left ventricular minimum and end diastolic pressures were 2.9 ± 2.0 and 1.7 ± 1.2 mm Hg (n = 26), respectively, and for right ventricular systolic pressures was 2.2 ± 1.5 mm Hg (n = 11). Two adverse events occurred during Definity infusion; both were resolved.

CONCLUSIONS

These results indicate that the SHAPE technique with Definity microbubbles is encouragingly efficacious for obtaining intracardiac pressures noninvasively and accurately. (Noninvasive, Subharmonic Intra-Cardiac Pressure Measurement; NCT03243942).

Risk factors and outcomes of myocardial injury after non-cardiac surgery in high-risk patients who underwent radical cystectomy

Radical cystectomy is considered the standard treatment for patients with muscle-invasive bladder tumors and has high postoperative complication rates among urological surgeries. High-risk patients, defined as those ≥45 years of age with history of coronary artery disease, stroke, or peripheral artery disease or those ≥65 years of age, can have a higher incidence of cardiac complications. Therefore, we evaluated the incidence, risk factors, and outcomes of myocardial injury after non-cardiac surgery (MINS) in high-risk patients who underwent radical cystectomy.This retrospective observational study analyzed 248 high-risk patients who underwent radical cystectomy. MINS was defined as serum troponin I concentration ≥0.04 mg/L within postoperative 3 days. The risk factors for MINS were evaluated by multivariate logistic regression analysis. Postoperative outcomes were evaluated. The 1-year survival after radical cystectomy was also compared between patients who developed MINS (MINS group) and those who did not (non-MINS group) by Kaplan-Meier analysis.MINS occurred in 35 patients (14.1%). Multivariate logistic regression analysis showed that early diastolic transmitral filling velocity (E)/early diastolic septal mitral annular velocity (E') ratio (odds ratio = 1.102, 95% confidence interval [1.009-1.203], P = .031) and large volume blood transfusion (odds ratio = 2.745, 95% confidence interval [1.131-6.664], P = .026) were significantly associated with MINS in high-risk patients who underwent radical cystectomy. Major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group (17.1% vs 6.1%, P = .035; 28.6% vs 12.7%, P = .021, respectively). Kaplan-Meier analysis showed significantly lower 1-year survival in the MINS group than in the non-MINS group (P = .010).MINS occurred in 14.1% of patients. High E/E' ratio and large volume blood transfusion were risk factors for MINS in high-risk patients who underwent radical cystectomy. Postoperative major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group. Preoperative evaluation of risk factors for MINS may provide useful information to detect cardiovascular complications after radical cystectomy in high-risk patients.

The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging?

Noninvasive imaging, particularly echocardiography, plays a central role in the evaluation for heart failure with preserved ejection fraction (HFpEF). Echocardiography helps to rule in HFpEF among patients with unexplained dyspnea when the diagnosis is uncertain. In established HFpEF, echocardiography provides important insights into pathophysiology and phenotyping, such as isolated left ventricular diastolic dysfunction, left atrial dysfunction, abnormal right ventricular-pulmonary artery coupling, ischemia, or obesity phenotypes. In addition, imaging enables risk stratification for HFpEF. This article provides a critical appraisal of the role of echocardiography in the diagnosis and evaluation of HFpEF.

Non-Invasive Intra-cardiac Pressure Measurements Using Subharmonic-Aided Pressure Estimation: Proof of Concept in Humans

This study evaluated the feasibility of employing non-invasive intra-cardiac pressure estimation using subharmonic signals from ultrasound contrast agents in humans. This institutional review board-approved proof-of-concept study included 15 consenting patients scheduled for left and right heart catheterization. During the catheterization procedure, Definity was infused intra-venously at 4-10 mL/min. Ultrasound scanning was performed with a Sonix RP using pulse inversion, three incident acoustic output levels and 2.5-MHz transmit frequency. Radiofrequency data were processed and subharmonic amplitudes were compared with the pressure catheter data. The correlation coefficient between subharmonic signals and pressure catheter data ranged from -0.3 to -0.9. For acquisitions with optimum acoustic output, pressure errors between the subharmonic technique and catheter were as low as 2.6 mmHg. However, automatically determining optimum acoustic output during scanning for each patient remains to be addressed before clinical applicability can be decided.

Diagnostic Accuracy of Tissue Doppler Index E/e' for Evaluating Left Ventricular Filling Pressure and Diastolic Dysfunction/Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Background

Tissue Doppler index E/è is used clinically and in multidisciplinary research for estimation of left ventricular filling pressure (LVFP) and diastolic dysfunction (DD)/heart failure with preserved ejection fraction (HFpEF). Its diagnostic accuracy is not well studied.

Methods and Results

From the PubMed, Scopus, Embase, and Cochrane databases, we identified 24 studies reporting E/è and invasive LVFP in preserved EF (≥50%). In random‐effects models, E/è had poor to mediocre linear correlation with LVFP. Summary sensitivity and specificity (with 95% CIs) for the American Society of Echocardiography–recommended E/è cutoffs (lateral, mean, and septal, respectively) to identify elevated LVFP was estimated by using hierarchical summary receiver operating characteristic analysis. Summary sensitivity was 30% (9–48%), 37% (13–61%), and 24% (6–46%), and summary specificity was 92% (82–100%), 91% (80–99%), and 98% (92–100%). Positive likelihood ratio (LR+) was <5 for lateral and mean E/è. LR+ was slightly >10 for septal E/è obtained from 4 studies (cumulative sample size <220). For excluding elevated LVFP, summary sensitivity for E/è (lateral, mean, and septal, respectively) was 64% (38–86%), 36% (3–74%), and 50% (14–81%), while summary specificity was 73% (54–89%), 83% (49–100%), and 89% (66–100%). Because of data set limitations, meaningful inference for identifying HFpEF by using E/è could not be drawn. With the use of quality assessment tool for diagnostic accuracy studies (Quality Assessment of Diagnostic Accuracy Studies questionnaire), we found substantial risks of bias and/or applicability.

Conclusions

There is insufficient evidence to support that E/è can reliably estimate LVFP in preserved EF. The diagnostic accuracy of E/è to identify/exclude elevated LVFP and DD/HFpEF is limited and requires further validation in a well‐designed prospective clinical trial.

Left atrial minimum volume is more strongly associated with N-terminal pro-B-type natriuretic peptide than the left atrial maximum volume in a community-based sample

Previous data have demonstrated that left atrial (LA) minimum volume indexed for body surface area (LAVImin) is more strongly associated with the Doppler echocardiographic E/e′ ratio than LA maximum volume index (LAVImax). We sought to explore if LAVImin was more closely related to serum levels of NT-proBNP than LAVImax and E/e′ in the community. A community-based sample of 730 subjects underwent echocardiographic examinations and NT-proBNP measurements. The mean age of the participants was 66.3 years (range 38–86) and 72 % were men. Age (Spearman correlation [rho] 0.533), LAVImin (rho 0.460), LAVImax (rho 0.360), estimated glomerular filtration rate (rho −0.349), and E/e′ (rho 0.301; all P < 0.001) were strongly correlated with log-NT-proBNP. In a multiple linear regression model with log-NT-proBNP as dependent variable and LAVImin, LAVImax, E/e′ ratio, and potential confounders as predictors, an adjusted R² of 44.9 % was obtained. When excluding either of LAVImin (R² 42.6 %, P < 0.001) or E/e′ (R² 44.6 %, P = 0.019) the model fit was significantly reduced. In contrast, when LAVImax was excluded the model fit was preserved (R² 45.0 %, P = 0.69). To detect an NT-proBNP level of >125 ng/L, LAVImin yielded a significantly larger area under the receiver operating characteristic curve (AUC) of 0.749 than LAVImax (AUC 0.701; P < 0.001) and E/e′ (AUC 0.661; P < 0.001). In our community-based sample, LAVImin was more strongly associated with NT-proBNP than LAVImax. Moreover, the discriminatory power to detect an elevated NT-proBNP level was stronger in LAVImin than in LAVImax and E/e′. Our findings support previous data that LAVImin may be more closely related to LV filling function than LAVImax.

"Left ventricular filling pressure(s)" - Ambiguous and misleading terminology, best abandoned

The use of the terms "left ventricular filling pressure" and "left ventricular filling pressures" is widespread in the cardiology literature, but the meanings ascribed to these terms have not been consistent. Left ventricular end-diastolic pressure (LVEDP) and mean left atrial pressure (LAP) cannot be used interchangeably as they will often differ in magnitude in the presence of cardiac disease and they also have different clinical significance. LVEDP is the best pressure to use when considering left ventricular function, whereas mean LAP is the most relevant pressure when considering the tendency to pulmonary congestion. The mean LAP is also the most relevant pressure for determining whether pulmonary hypertension has a left heart (post-capillary) component. If only a left ventricular pressure tracing is available then a technique to measure the mean left ventricular diastolic pressure is the best option for estimating the mean LAP. If only right heart pressures are available then the pulmonary artery end-diastolic pressure will provide a reasonable estimate of LVEDP, but only when the heart and pulmonary circulation are normal. If there is mitral valve disease, left ventricular disease or pulmonary hypertension the LVEDP cannot be estimated from right heart pressures. The problem of the ambiguity of "filling pressure (s)" is readily solved by the abandonment of this term and the use of either LVEDP or mean LAP as appropriate.

Mitral flow propagation velocity in non-sedated healthy cats

Mitral flow propagation velocity (Vp) is an index used to evaluate the left ventricular diastolic function. Its influence on human and small animal cardiopathies has been studied; however there are few reports evaluating this variable in domestic felines. In addition, there is a lack of studies in non-sedated healthy cats. Therefore, the purpose of this study was to establish values for Vp and its correlation with other echocardiographic indexes in non-sedated healthy cats in order to provide new perspectives related to diastolic function in this species. Twenty-six clinically healthy cats were submitted to echocardiography to assess the animals' cardiac conditions. Variables such as age, heart rate (HR), body surface area (BSA), initial (E mitral) and late (A mitral) ventricular filling waves, isovolumic relaxation time (IVRT) and E/IVRT relation were correlated to Vp. No proven relation between any of these variables and Vp was observed in this present study, except for HR and BSA. In the variability analysis, higher values were verified for inter-observer analysis. This study concludes that Vp proved to be an useful index for estimating left ventricular relaxation in non-sedated healthy domestic cats and provides reference ranges for this variable.

Contrast stress echocardiography in hypertensive heart disease

Hypertension is associated with atherosclerosis and cardiac and vascular structural and functional changes. Myocardial ischemia may arise in hypertension independent of coronary artery disease through an interaction between several pathophysiological mechanisms, including left ventricular hypertrophy, increased arterial stiffness and reduced coronary flow reserve associated with microvascular disease and endothelial dysfunction. The present case report demonstrates how contrast stress echocardiography can be used to diagnose myocardial ischemia in a hypertensive patient with angina pectoris but without significant obstructive coronary artery disease. The myocardial ischemia was due to severe resistant hypertension complicated with concentric left ventricular hypertrophy and increased arterial stiffness.

Noninvasive prediction of left ventricular end-diastolic pressure in patients with coronary artery disease and preserved ejection fraction

BACKGROUND

The aim of this study was to compare 3 different available methods for estimating left ventricular end-diastolic pressure (LVEDP) noninvasively in patients with coronary artery disease and preserved left ventricular ejection fraction (EF).

METHODS

We used 3 equations for noninvasive estimation of LVEDP: The equation of Mulvagh et al., LVEDP(1) = 46 - 0.22 (IVRT) - 0.10 (AFF) - 0.03 (DT) - (2 ÷ E/A) + 0.05 MAR; the equation of Stork et al., LVEDP(2) = 1.06 + 15.15 × Ai/Ei; and the equation of Abd-El-Aziz, LVEDP(3) = [0.54 (MABP) × (1 - EF)] - 2.23. (

ABBREVIATIONS

A, A-wave velocity; AFF, atrial filling fraction; Ai, time velocity integral of A wave; DT, deceleration time; E, E-wave velocity; Ei, time velocity integral of E wave; IVRT, isovolumic relaxation time; MABP, mean arterial blood pressure; MAR, time from termination of mitral flow to the electrocardiographic R wave; Ti, time velocity integral of total wave.)

RESULTS

LVEDP measured by catheterization was correlated with LVEDP(1) (r = 0.52, P < 0.001), LVEDP(2) (r = 0.31, P < 0.05), and LVEDP(3) (r = 0.81, P < 0.001).

CONCLUSIONS

The equation described by Abd-El-Aziz, LVEDP = [0.54 MABP × (1 - EF)] - 2.23, appears to be the most accurate, reliable, and easily applied method for estimating LVEDP noninvasively in patients with preserved left ventricular ejection fraction and an LVEDP < 20 mm Hg.

Value of NT-ProBNP level and echocardiographic parameters in ST-segment elevation myocardial infarction treated by primary angioplasty: relationships between these variables and their usefulness as predictors of ventricular remodeling

INTRODUCTION AND OBJECTIVES

To assess the value of N-terminal fragment of brain natriuretic peptide (NT-proBNP) measurement and echocardiography for predicting ventricular remodeling after myocardial infarction and to investigate relationships between the NT-proBNP level and echocardiographic parameters at discharge and in the medium term.

METHODS

The study involved 159 patients with myocardial infarction treated by primary coronary angioplasty. The NT-proBNP level was measured on admission, at discharge and after 6 months. Echocardiography was performed at discharge and after 6 months.

RESULTS

Overall, 31 patients (19.5%) demonstrated remodeling. At discharge, the variables associated with remodeling were: mitral inflow E-wave-to-A-wave velocity ratio (E/A), systolic mitral annulus velocity (Sm), early diastolic mitral annulus velocity (Em), the mitral inflow E wave to early diastolic mitral annulus velocity ratio (E/ Em), left atrial volume (LAV), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and discharge NT-proBNP level. Only E/Em was an independent predictor of ventricular remodeling (odds ratio [OR]=1.143; 95% confidence interval [CI], 1.039-1.258; P=.006). At discharge, correlations were observed between the NT-proBNP level and LVEDV, LVESV, ejection fraction (EF) and E/Em. At 6 months, correlations with ventricular volumes and EF were unchanged, the correlation with E/Em was better (r=0.47 vs. r=0.69), and a modest correlation with LAV developed (r=0.43; P=.001).

CONCLUSIONS

The E/Em ratio was the best echocardiographic predictor of left ventricular remodeling after myocardial infarction. The NT-proBNP level had no additional predictive value over echocardiography. Correlations between the NT-proBNP level and ventricular volumes and EF at discharge and 6 months were similar, while correlations with E/Em and LAV were better at 6 months.

Cardiac dysfunction assessed by echocardiographic tissue Doppler imaging is an independent predictor of mortality in the general population

BACKGROUND

Tissue Doppler imaging (TDI) detects left ventricular dysfunction in patients with heart failure and normal ejection fraction, but the prognostic significance of left ventricular dysfunction by TDI in the general population is unknown.

METHODS AND RESULTS

Within the Copenhagen City Heart Study, a large community-based population study, cardiac function was evaluated in 1036 participants by both conventional echocardiography and TDI. Averages of peak systolic (s'), early diastolic (e'), and late diastolic (a') velocities from 6 mitral annular sites were used. TDI was furthermore quantified by a combined index (eas index) of diastolic and systolic performance: e'/(a' x s'). During follow-up (median, 5.3 years), 90 participants died. Left ventricular dysfunction by TDI, in terms of low s' (hazard ratio, 1.23 per 1-cm/s decrease; P<0.05) and a' (hazard ratio, 1.20 per 1-cm/s decrease; P=0.001), were significant predictors of death in Cox proportional-hazards models adjusted for clinical variables (age, sex, body mass index, heart rate, hypertension, diabetes mellitus, and ischemic heart disease) and conventional echocardiography. The adjusted hazard ratio for death in the third tertile compared with the first tertile of the combined index of systolic and diastolic performance by TDI was 2.5 (P<0.005).

CONCLUSIONS

In the general population, in which most are free of left ventricular systolic dysfunction and restrictive diastolic filling using conventional echocardiographic parameters, left ventricular dysfunction by TDI is a powerful and independent predictor of death, especially when systolic performance and diastolic performance are considered together, recognizing their interdependency and their complex relation to deteriorating cardiac function.

Preclinical systolic and diastolic dysfunction assessed by tissue Doppler imaging is associated with elevated plasma pro-B-type natriuretic peptide concentrations

BACKGROUND

Heart failure is a major public health problem. To improve its grave prognosis, early identification of cardiac dysfunction is mandatory. Conventional echocardiography is not suitable for this. Tissue Doppler imaging (TDI), however, could be so.

METHODS AND RESULTS

Within a large community-based population-study (n = 1012), cardiac function was evaluated by conventional echocardiography (left ventricular hypertrophy, dilatation, systolic, and severe diastolic dysfunction), TDI, and plasma proBNP. Averages of peak systolic (s'), early diastolic (e'), and late diastolic (a') velocities from 6 mitral annular sites were used. TDI was furthermore quantified by a combined index (eas-index) of diastolic and systolic performance: e'/(a' x s'). Compared with controls, persons with elevated plasma proBNP concentrations (n = 100) displayed lower systolic and diastolic performance by TDI, in terms of lower s' (P = 0.017) and a' (P < .001), and higher e'/a' (P = .002) and eas-index (P < .001). This pattern remained significant after multivariable adjustment for age, sex, body mass index, heart rate, estimated glomerular filtration rate, hypertension, diabetes, ischemic heart disease, and conventional echocardiography. Furthermore, TDI provided incremental information over conventional echocardiography in predicting elevated plasma proBNP concentrations.

CONCLUSIONS

Preclinical systolic and diastolic dysfunction by TDI is associated with elevated plasma proBNP levels, even when conventional echocardiography is normal.

Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure

BACKGROUND

The ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) has been correlated with pulmonary capillary wedge pressure (PCWP) in a wide variety of cardiac conditions. The objective of this study was to determine the reliability of mitral E/Ea for predicting PCWP in patients admitted for advanced decompensated heart failure.

METHODS AND RESULTS

Prospective consecutive patients with advanced decompensated heart failure (ejection fraction < or =30%, New York Heart Association class III to IV symptoms) underwent simultaneous echocardiographic and hemodynamic evaluation on admission and after 48 hours of intensive medical therapy. A total of 106 patients were included (mean age, 57+/-12 years; ejection fraction, 24+/-8%; PCWP, 21+/-7 mm Hg; mitral E/Ea ratio, 20+/-12). No correlation was found between mitral E/Ea ratio and PCWP, particularly in those with larger left ventricular volumes, more impaired cardiac indexes, and the presence of cardiac resynchronization therapy. Overall, the mitral E/Ea ratio was similar among patients with PCWP >18 and < or =18 mm Hg, and sensitivity and specificity for mitral E/Ea ratio >15 to identify a PCWP >18 mm Hg were 66% and 50%, respectively. Contrary to prior reports, we did not observe any direct association between changes in PCWP and changes in mitral E/Ea ratio.

CONCLUSIONS

In decompensated patients with advanced systolic heart failure, tissue Doppler-derived mitral E/Ea ratio may not be as reliable in predicting intracardiac filling pressures, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac resynchronization therapy.

Echocardiographic assessment of left ventricular diastolic function and filling pressure in atrial fibrillation

Diastolic dysfunction has been linked to 2 epidemics: atrial fibrillation (AF) and heart failure. The presence and severity of diastolic dysfunction are associated with an increased risk for first AF and first heart failure in patients with sinus rhythm. Furthermore, the risk for heart failure is markedly increased once AF develops. The evaluation of diastolic function once AF has developed remains a clinical challenge. The conventional use of Doppler echocardiography for the assessment and grading of diastolic dysfunction relies heavily on evaluating the relation of ventricular and atrial flow characteristics. The mechanical impairment of the left atrium and the variable cycle lengths in AF render the evaluation of diastolic function difficult. A few Doppler echocardiographic methods have been proved clinically useful for the estimation of diastolic left ventricular filling pressures in AF, but these appear to be underutilized. Several innovative methods are emerging that promise to provide greater precision in diastolic function assessment, but their clinical utility in AF remains to be established. In conclusion, this review provides an up-to-date discussion of the evaluation of diastolic function assessment in AF and how it may be important in the clinical management of patients with AF.

Age-dependency of classic and new parameters of diastolic function

Age-dependency has been demonstrated for classic diastolic parameters but is less documented for novel markers. We compared wide spectrum of diastolic measurements in healthy subjects younger and older than 50 and 70 years.

METHOD

In 80 subjects (17 to 91 year, 38 male, mean age 53 +/- 16) we assessed in transthoracic echocardiography mitral inflow, pulmonary vein flow, propagation velocity, and tissue Doppler parameters. The data were compared between the groups: A < 50, B 50-70, and C > 70 years and their correlation with age was analyzed.

RESULT

In the older groups a longer duration of isovolumic relaxation, higher velocity of mitral inflow atrial phase, and lower early to atrial mitral inflow velocity ratio (E/A) were observed. In pulmonary veins ratio of peak systolic to diastolic velocity (S/D) was higher and atrial reversal flow faster. Among the new parameters in older groups a lower propagation velocity of early wave (Ep) (30 +/- 8 in C, 44 +/- 10 in B vs 49+/-9 cm/s in A;P< 0.05) and peak early diastolic velocity of mitral annulus (E' 9.5 +/- 1.8 in C and 11.2 +/- 2.9 in B vs 15.8 +/- 4.1 cm/s in A,P< 0.05) were recorded.

CONCLUSIONS

Besides the evolution of mitral inflow toward the delayed relaxation profile in elderly, a decrease of propagation and tissue Doppler velocities were documented. The strongest positive correlation with age was observed for atrial velocity of mitral inflow (A, r = 0.63) and inverse correlation for E/A ratio (r =-0.6) and early diastolic velocity of mitral annulus (r =-0.69).

Usefulness of the pulmonary arterial systolic pressure to predict pulmonary arterial wedge pressure in patients with normal left ventricular systolic function

Tissue Doppler imaging combined with transmitral Doppler permits estimation of pulmonary artery wedge pressure (PAWP) in many, but not all, patients, whereas pulmonary artery systolic pressure (PASP) and cardiac output (time-velocity integral method) are routinely measured. It was hypothesized that simple Doppler echocardiographic measurements could be used to estimate PAWP in many patients by rearranging the equation for pulmonary vascular resistance ([mean pulmonary artery pressure - (left atrial pressure/cardiac output)] x 80). Data from 69 patients (mean age 59 +/- 15 years) were reviewed, including cardiac output, transmitral mitral E wave velocity, and lateral tissue Doppler imaging mitral annular early diastolic velocity. PAWP was determined in the 2 ways of (1) measured (PAWPm) using the regression equation PAWPm = 1.91 + (1.24 * transmitral mitral E wave velocity/mitral annular early diastolic velocity) developed and validated by Nagueh, and (2) using a nomogram that we developed to predict PAWP when cardiac output and PASP were known. Moderately strong correlation was found between PASP and PAWPm (r = 0.73), and this correlation improved when excluding patients with pulmonary or liver disease and restricting cardiac output to 3.5 to 6.0 L/min (physiologic range; r = 0.81). Furthermore, the relation between PAWPm and PASP allowed for discrimination of high versus low PAWP: 36 of 37 patients with PASP < or =30 mm Hg had PAWPm < or =15 mm Hg (sensitivity 97%, specificity 47%). Conversely, 9 of 9 patients with PASP > or =40 mm Hg had PAWPm > or =12 mm Hg (sensitivity 100%, specificity 70%). Predicted PAWP correlated well with PAWPm (r = 0.63) and improved when patients with liver or pulmonary disease were excluded (r = 0.83). In conclusion, PASP strongly correlated with PAWP, and this principle can be exploited to rapidly detect patients with low or high PAWP.

Enlarged left atrium is a simple and strong predictor of poor prognosis in patients after myocardial infarction

BACKGROUND AND AIM

Patients after myocardial infarction (MI) differ according to the extend of myocardial damage and prognosis. Diastolic function impairment may have great impact on development of heart failure and outcomes. We evaluated the prognostic value of various echocardiographic measurements in 18-month and 3-year observation after MI.

METHODS

60 patients after MI (44 male, mean age 60 +/- 11) were examined by transthoracic echocardiography with the assessment of wide spectrum of parameters. Mortality and combined end points (cardiac deaths and heart failure exacerbation) were assessed after 18-month and 3-year observation and groups with and without end points were compared. Optimal cutoff values were estimated by receiver operating characteristic (ROC) analysis and resulting Kaplan-Meier curves were compared.

RESULTS AND CONCLUSIONS

After 18 months, 11 deaths occurred and 20 subjects experienced hospitalization caused by heart failure exacerbation. Although the group with cardiac events showed a greater enlargement of the left ventricle and lower ejection fraction, the highest relative risk of poor outcome (RR = 5.0) was related to the left atrial enlargement above 44 mm. Although restrictive or pseudonormal inflows were connected with 2.1 relative risk of combined end point, all patients with E deceleration time < or = 130 ms experienced heart failure exacerbation or death. Despite tissue Doppler and propagation parameters describing elevated end-diastolic pressure differed between groups with various outcomes in multivariate analysis, only enlarged left atrium was an independent predictor for both combined end point and cardiac death. Further 3-year follow-up solely confirmed the role of above described predictors.

Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: review of the literature and clinical recommendations

Tissue Doppler imaging is an echocardiographic technique that directly measures myocardial velocities. Diastolic tissue Doppler velocities reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (transmitral early diastolic velocity/mitral annular early diastolic velocity [E/Ea]) have been developed to noninvasively estimate left ventricular (LV) filling pressure. Consequently, mitral E/Ea can help to establish the presence of clinical congestive heart failure in patients with dyspnea. However, E/Ea has a significant 'gray zone', and is not well validated in nonsinus rhythm and mitral valve disease. B-type natriuretic peptide (BNP) is a protein released by the ventricles in the presence of myocytic stretch, and has been correlated to LV filling pressure and, independently, to other cardiac morphological abnormalities. In addition, BNP is significantly affected by age, sex, renal function and obesity. Given its correlation with multiple cardiac variables, BNP has high sensitivity, but low specificity, for the detection of elevated LV filling pressures. Taking into account the respective strengths and limitations of BNP and mitral E/Ea, algorithms combining them can be used to more accurately estimate LV filling pressures in patients presenting with dyspnea.

Determination of left ventricular filling pressure by new echocardiographic methods in patients with coronary artery disease

AIM

The present study was designed to determine the reliability of the analysis of the time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity and mean systolic strain index, and comparing them with E/E' in the detection of increased left ventricular end-diastolic pressure (LVEDP) in patients with coronary artery disease.

METHODS

Eighty patients (mean age: 57.2 +/- 11.5 years) referred for cardiac catheterization were studied. Patients were divided into 2 groups according to LVEDP (group 1: LVEDP > 20 mmHg, n = 39 patients; group 2: LVEDP < or = 20 mmHg, n = 41 patients). From the mitral inflow, peak E velocity was calculated. With tissue Doppler echocardiography, early diastolic velocity (E') measured from the septal, lateral, inferior and lateral mitral annulus and mean value of E' and E/E' ratio were calculated. The time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity (T(E'-E)) was calculated. From the apical chambers, the peak systolic strain value of 16 left ventricular (LV) segments was measured and the mean of these 16 segments was calculated and referred to as mean systolic strain index.

RESULTS

The patients with increased LVEDP (group 1) had a higher E/E' ratio (13.8 +/- 3.4 vs. 9.9 +/- 2.8, P < 0.001) and lower mean systolic strain index (11.8 +/- 3.4 % vs. 13.5 +/- 3.6 %, P = 0.038) than patients in group 2. The sensitivity of E/E' > 13.42 for identifying LVEDP > 20 mmHg was 71%, with a specificity of 89%. The sensitivity of a mean systolic strain index < 10.57% for identifying LVEDP > 20 mmHg was 44%, with a specificity of 83%. T(E'-E )was not significantly different between the two groups.

CONCLUSION

The decreased longitudinal function of the left ventricle is related to increased LVEDP. The E/E' ratio, which in recent years has been used for the prediction of LV filling pressures, was a better predictor for increased LVEDP than the mean systolic strain score index and the time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity in patients with coronary artery disease.

Global and regional evaluation of systolic and distolic left ventricular temporal parameters using a novel program for ECG-gated myocardial perfusion SPECT

BACKGROUND

A newly developed program, named cardioGRAF, enabled the evaluation of left ventricular (LV) systolic and diastolic temporal parameters for the estimation of heart failure using ECG-gated myocardial perfusion SPECT (GMPS).

OBJECTIVE

The feasibility of those global (g-) and regional (r-) parameters was validated to compare with gated equilibrium radionuclide angiography (ERNA) and speckle-tracking radial strain (STS) from echocardiography.

METHODS

Thirty-three patients were studied using GMPS and ERNA (n=11) or GMPS and STS (n=22). The following g- or r-parameters obtained by cardioGRAF and ERNA or STS were compared: time to end systole (TES), time from end systole to peak filling rate (TPF1), time from 0 to peak filling rate (TPF2), time to peak radial strain (TPS), time from peak strain to peak negative strain rate (TP-SR1), and time from 0 to peak negative strain rate (TP-SR2).

RESULTS

All g-parameters were successfully obtained by cardioGRAF and ERNA. The results demonstrated good correlations (g-TES: r = 0.79, p < 0.005; g-TPF1: r = 0.75, p < 0.02; TPF2: r = 0.83, p < 0.005). The differences were 11.9 +/- 31.8 ms in g-TES, 19.9 +/- 65.4 ms in g-TPF1, and 37.7 +/- 67.4 ms in g-TPF2. All r-parameters were successfully obtained by cardioGRAF. Eight patients and 12 segments were excluded because of the inadequate quality of routine echocardiography for STS analysis. However, r-parameters obtained by cardioGRAF were significantly correlated with those of STS (r-TES and r-TPS: r = 0.61, p = 1 x 10(-8); r-TPF1 and r-TP-SR1: r = 0.69, p = 3 x 10(-11); r-TPF2 and r-TP-SR2: r = 0.76, p = 2 x 10(-15)). The differences were 22.1 +/- 38.2 ms between r-TES and r-TPS, 7.0 +/- 123.4 ms between r-TPF1 and r-TP-SR1, and 38.1 +/- 111.5 ms between r-TPF2 and r-TP-SR2.

CONCLUSION

The feasibility of evaluating systolic and diastolic temporal parameters by a new program was validated. This program has the potential to evaluate both diastolic and systolic heterogeneous wall motions which express dyssynchrony in heart failure.