Annular Tissue Doppler Imaging Research Articles

Ultrasound Findings with Bedside Ultrasound of Heart Failure with Preserved LVEF

Heart failure with preserved ejection fraction (HFpEF), formerly termed diastolic heart failure, constitutes nearly half the heart failure cases. Patients may exhibit acute heart failure symptoms, yet bedside echocardiograms might indicate normal left ventricular systolic function, potentially leading to the premature exclusion of heart failure as a differential diagnosis. This review delves into fundamental echocardiographic principles associated with diastolic dysfunction, crucial for recognition in HFpEF patients. Specifically, it explores the VALVE protocol, a stepwise approach tailored for the exigent nature of emergency departments. Acquiring accurate imaging windows in acutely ill patients poses a challenge, emphasizing the significance of precise measurements to avoid errors. Techniques such as E-point septal separation (EPSS) must be meticulously positioned for ejection fraction determinations. The discussion focuses on key metrics outlined in the VALVE protocol, encompassing ventricular function, annular tissue Doppler imaging (TDI) measurements, left atrium volume, mitral valve velocities, and the E/e0 ratio as indicators of diastolic dysfunction in HFpEF.

Right ventricular function in patients with significant tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Aim The aim of this meta-analysis was to systematically investigate the prognostic value of right ventricular (RV) function in all-comers patients with significant (at least moderate, ≥ 2+) tricuspid regurgitation (TR). Background Chronic significant TR imposes a volume overload to the RV leading to a progressive RV dilatation and dysfunction. A comprehensive assessment of RV function is of paramount importance to guide the therapeutic management of these patients; however, it remains challenging, particularly in presence of altered loading conditions. Methods MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to July 2022. Studies reporting data on at least one echocardiographic RV function parameter and outcome in patients with significant TR were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was all-cause long-term mortality (more than one year). Results Out of 3,152 studies, a total of 10 were included in the analytic synthesis, enrolling 3435 subjects. The median follow-up in our study population was 28 [22 – 70] months. All-cause long-term mortality was 40% (95% confidence interval [CI]: 32–49%, p = 0.028; Figure 1). To explore the potential impact of effect size modifiers on all-cause long-term mortality, we performed a meta-regression analysis of the baseline characteristics of the included studies. At long-term, a significant relation was found between RV fractional area change (RV-FAC), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular tissue doppler imaging systolic velocity (TDI s’) and mortality. In particular, RV-FAC was associated with reduced incidence of all-cause mortality [7 studies enrolling 2,611 subjects, intercept 5.18, slope −0.15, P = 0.007; Figure 2]; whereas both TAPSE and TDI s’ were unsatisfactory to predict the outcome in these patients [TAPSE 9 studies enrolling 2,891 subjects, intercept 1.73, slope −0.12, P = 0.36; TDI s’ 5 studies enrolling 1429 subjects, intercept −2.06, slope 0.15, P = 0.78]. Interestingly, diabetes mellitus (DM) and hyperlipidaemia were associated with an increased risk of mortality [DM 9 studies enrolling 3371 subjects, intercept −2.62, slope 0.09, P = 0.004; hyperlipidaemia 6 studies enrolling 2338 subjects, intercept −2.91, slope 0.05, P = 0.01]. Conclusions Significant TR is associated with increased risk of all-cause. To our knowledge, this is the first study to demonstrate that only RV-FAC, and not conventional echocardiographic indexes of RV longitudinal function, correlates with adverse outcomes in patients with significant TR.

Right Ventricular Dysfunction Predicts Outcome in Acute Heart Failure.

AimThe severity of cardiac impairment in acute heart failure (AHF) predicts outcome, but challenges remain to identify prognostically important non-invasive parameters of cardiac function. Left ventricular ejection fraction (LVEF) is relevant, but only in those with reduced LV systolic function. We aimed to assess the standard and advanced parameters of left and right ventricular (RV) function from echocardiography in predicting long-term outcomes in AHF.MethodsA total of 418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bedside echocardiography within 24 h of recruitment. We retrospectively assessed 8 RV and 5 LV echo parameters of the cardiac systolic function to predict 2-year mortality, using both guideline-directed and study-specific cutoffs, based on the maximum Youden indices via ROC analysis. For the RV, these were the tricuspid annular plane systolic excursion, RV fractional area change, tissue Doppler imaging (TDI) peak tricuspid annular systolic wave velocity, both peak- and end-systolic RV free wall global longitudinal strain (RV GLS) and strain rate (mean RV GLSR), RV ejection fraction (RVEF) derived from a 2D ellipsoid model and the ratio of the TAPSE to systolic pulmonary artery pressure (SPAP). For the LV, these were the LVEF, mitral regurgitant ΔP/Δt (MR dP/dt), the lateral mitral annular TDI peak systolic wave velocity, LV GLS, and the LV GLSR.ResultsA total of 7/8 parameters of RV systolic function were predictive of 2-year outcome, with study cutoffs like international guidelines. A cutoff of < −1.8 s–1 mean RV GLSR was associated with worse outcome compared to > −1.8 s–1 [HR 2.13 95% CI 1.33–3.40 (p = 0.002)]. TAPSE:SPAP of > 0.027 cm/mmHg (vs. < 0.027 cm/mmHg) predicted worse outcome [HR 2.12 95% CI 1.53–2.92 (p < 0.001)]. A 3-way comparison of 2-year mortality by LVEF from the European Society of Cardiology (ESC) guideline criteria of LVEF > 50, 41–49, and < 40% was not prognostic [38.6% vs. 30.9 vs. 43.9% (p = 0.10)]. Of the 5 parameters of LV systolic function, only an MR dP/dt cutoff of < 570 mmHg was predictive of adverse outcome [HR 1.63 95% CI 1.01–2.62 (p = 0.047)].ConclusionWith cutoffs broadly like the ESC guidelines, we identified RV dysfunction to be associated with adverse prognosis, whereas LVEF could not identify patients at risk.

Tricuspid Annular Systolic Velocity to Left Ventricular Outflow Velocity Time Integral Ratio: Proof of Concept Utility Analysis.

BackgroundThe tricuspid annular plane systolic excursion (TAPSE) / pulmonary artery systolic pressure (PASP) ratio has been a useful marker of right ventricular (RV)-pulmonary artery coupling. However, given the intricate functional and mechanical interdependence of the right and left ventricles, we believe this ratio would be less useful when assessing reduced left ventricular (LV) systolic function. Instead, we proposed using the tricuspid annular tissue Doppler imaging systolic velocity to LV outflow tract velocity time integral ratio (TA TDI s’ / LVOT VTI r) for this purpose. MethodsFor this proof-of-concept study, a retrospective analysis was conducted on 60 patients with complete echocardiographic studies while in sinus rhythm. The population was divided as follows; Group 1 included 20 individuals with normal left ventricular ejection fraction (LVEF) as well as normal RV and PASP. Group 2 was composed of 20 patients known to have been evaluated or treated for pulmonary hypertension, while group 3 was comprised of 20 patients treated for heart failure (HF). ResultsTAPSE/PASP ratios were no different from any of the studied groups. However, the proposed TA TDI s' /LVOT VTI r was statistically different among all three groups (Group 1: 0.6 ± 0.1*; Group 2: 0.5 ± 0.1°; and Group 3: 0.8 ± 0.3#; p < 0.001).ConclusionsBased on these results, there is now a need for additional prospective studies to explore the overall utility of using this TA TDI s' / LVOT VTI r in day-to-day routine assessments not only for diagnostic purposes but also to determine how this ratio correlates with symptoms and changes with therapy.

Marked reduction in right ventricular longitudinal contraction after cardiopulmonary bypass in patients with preserved right ventricular output

Introduction Assessment of right ventricular (RV) function is crucial since RV failure with a reduced cardiac output is associated with compromised outcome in cardiac surgery. Echocardiographic evaluation of RV function is commonly used, and a reduction in tricuspid annular plane systolic excursion (TAPSE) and tricuspid annulus tissue Doppler imaging (S’) have been observed independently of clinical signs of RV failure. This has led to uncertainty of these variables’ ability to reflect RV function in cardiac surgery [1]. The objective of this study was to describe changes in transoesophageal echocardiographic (TEE) measurements of TAPSE and S’ during coronary artery bypass graft (CABG) surgery with detailed haemodynamic monitoring using pulmonary artery catheter (PAC) assessment of RV output in patients undergoing uncomplicated CABG without RV impairment. Methods We prospectively studied 30 patients with concomitant PAC and TEE measurements at four time-points, namely after: anaesthesia induction, sternotomy, cardiopulmonary bypass (CPB) and upon arrival in the intensive care unit (ICU). Results TAPSE and S’ were significantly reduced by 43% (p Discussion TAPSE and S’ were both reduced after CPB despite maintained cardiac output. RVFAC, RVEF and RV-GLS remained stable, however, these measures were unable to detect minor changes in SV. 3D-echocardiography showed a strong correlation with SV measured by thermodilution, but with a consistent underestimation of approximately 10%. Our results suggest that 3D echocardiography is better at tracking RV output than other echocardiographic modalities, however, the clinician should be aware that 3D echocardiography underestimates SV compared to thermodilution.

Prognostic role of diastolic dysfunction in patients undergoing transcatheter aortic valve replacement.

Prior studies have shown that left ventricular diastolic dysfunction (DD) is associated with increased mortality after surgical aortic valve replacement but studies on transcatheter aortic valve replacement (TAVR) are limited and have not taken into account mitral annular calcification (MAC), which limits the use of mitral valve annular tissue Doppler imaging. We performed a single-center retrospective analysis to better evaluate the role of baseline DD on outcomes after TAVR. After excluding patients with atrial fibrillation, mitral valve prostheses and significant mitral stenosis, 359 consecutive TAVR patients were included in the study. Moderate-to-severe MAC was present in 58% of the patients. We classified patients into severe versus nonsevere DD based on the evaluation of elevated left ventricular filling pressure. The outcome measure was all-cause mortality or heart failure hospitalization. Over a mean follow-up time of 13 months, severe DD was associated with an increased risk for the outcome measure (HR 2.02 [1.23-3.30], p = .005). However, this association was lost in a propensity-matched cohort. In multivariate analysis, STS score was the only independent predictor of all cause mortality of heart failure hospitalization (HR 1.1 [1.05-1.15], p < .001). We evaluated the role of baseline DD on outcomes after TAVR by taking into account the presence of MAC. Severe DD was associated with increased all-cause mortality or heart failure hospitalization but not independently of other structural parameters and known predictors of the outcome measure.

Echocardiographic assessment of single-ventricle diastolic function and its correlation to short-term outcomes after the Fontan operation.

Postoperative complications after the Fontan operation for single ventricle heart disease are common and include persistent pleural drainage and prolonged length of hospital stay (LOS). Diastolic ventricular dysfunction may increase risk for postoperative complications by raising central venous pressures. We sought to determine the relationship between preoperative echocardiographic measurements of diastolic function, including myocardial deformation imaging, on (a) preoperative invasive catheterization measurements and (b) postoperative outcomes after the Fontan procedure. All patients that underwent Fontan procedure from 2011 to 2017 were included. Echocardiograms performed within 6months prior to Fontan operation were evaluated. Measurements of ventricular global and diastolic strain and strain rate were performed offline with TomTec speckle tracking software. Other diastolic function measurements included atrioventricular valve inflow and annular tissue Doppler imaging. Diastolic function measurements were correlated with pre-Fontan catheterization measurements and postoperative Fontan outcomes using Spearman's rho. Multivariable logistic regression for a prolonged LOS (>75%ile for postoperative LOS) was performed to adjust for preoperative risk factors. A total of 141 patients were included in the study. Majority had single morphologic right ventricle (58.9%). Median age at time of Fontan was 3.4years (IQR 2.9-4). Median hospital LOS was 9days (IQR 7-11). Circumferential diastolic strain rate weakly correlated with LOS (rho=-0.21, P=.01). There was no correlation between any other diastolic strain measurements and pre-Fontan end-diastolic pressure or postoperative LOS. In multivariable analysis, E/E' was the only echo measurement that predicted prolonged hospital LOS (OR 1.4, 95%CI: 1.1-1.8, P=.003). Preoperative diastolic strain measurements did not have a strong association with postoperative Fontan outcomes. Increased E/E' ratio, however, did predict greater LOS after Fontan procedure, and may be useful in preoperative risk stratification. Future studies are needed to further assess the utility of diastolic strain imaging in the single-ventricle population.

Qualitative Assessment of Color M-Mode Signals in the Evaluation of Left Ventricular Diastolic Function: A Proof of Concept Study

Although the most recent American Society of Echocardiography guidelines are a major step forward in echocardiographic evaluation of diastolic function, the ability to differentiate between normal and abnormal function remains challenging. The authors aimed to determine whether qualitative assessments of color M-mode flow displays could be a useful parameter in the evaluation of left ventricular (LV) diastolic dysfunction. Retrospective observational study. Tertiary care level hospital. The study comprised echocardiographic data from 105 consecutive patients. None. Patients were allocated into the following 3 groups according to the LV diastolic function based on current American Society of Echocardiography recommendation guidelines for LV diastolic dysfunction classification: group I-normal function (n = 40); group II-early relaxation abnormalities (grade I) (n = 50), and group III-elevated LV pressures (grade II) (n = 15). Patients with normal diastolic function were younger (45 ± 14 y) than those with diastolic dysfunction (group II: 64 ± 10 y and group III: 56 ± 15 y) (p < 0.05). Volumetric echocardiographic parameters and mitral inflow and mitral annulus tissue Doppler imaging measures were significantly different among the 3 studied groups (p < 0.05). Interestingly, qualitative assessment of color M-mode flows displayed distinctive signals based on the left ventricle filling properties. Intraobserver and interobserver variability to determine the reliability of these signals were robust (weighted kappa 0.84 ± 0.11 and 0.65 ± 0.13, respectively). Qualitative assessment of color M-mode flow displays offers simple and reliable information of potential usefulness in the evaluation of LV diastolic function.

Early myocardial changes in normotensive children of hypertensive parents: a tissue Doppler study.

The aim of this study was to examine early left ventricular systolic and diastolic changes using tissue Doppler imaging (TDI) in normotensive children of hypertensive parents (NCHP), a risk group for cardiovascular diseases. Ninety-two children characterized as NCHP (age range: 6-18 years) and 90 age-, gender-, height-, weight-, and body mass index-matched children characterized as normotensive children of normotensive parents (NCNP) were included in the study. Left ventricular diastolic parameters were assessed using transmitral flow pulse wave Doppler echocardiography and mitral septal and lateral annular TDI. Left ventricular systolic and diastolic function was evaluated globally using the TDI-derived myocardial performance index (MPI'). Mean systolic, diastolic, and average blood pressure values were found to be higher in the NCHP group than in the NCNP group. Echocardiographic parameters in the NCHP group showed statistically significant differences, including increased interventricular septum end-diastolic wall thickness (p = 0.039), left ventricular end-diastolic posterior wall thickness (p = 0.011), relative wall thickness (p = 0.013), and transmitral flow A velocity (p = 0.003); parameters determined by TDI included a prolonged isovolumetric relaxation time (p < 0.001) and isovolumetric contraction time (p = 0.002), shortened ejection time (p = 0.001), and increased MPI' (p < 0.001) in the NCHP group. Early alterations in myocardial function, indicated by increased MPI' values, had a positive correlation with systolic blood pressure and myocardial thickness. Conversely, they were negatively correlated with the ejection fraction and E/A ratio, which decreases with diastolic dysfunction. The MPI' is considered a repeatable, non-invasive, and low-cost assessment method that can surpass conventional methods in the detection of early left ventricular systolic and diastolic functional changes in the subclinical period of hypertension in children with familial risk.

Right ventricular (RV) echocardiographic parameters in patients with pulmonary thromboembolism (PTE).

BACKGROUNDAcute pulmonary thromboembolism (PTE) is a common disease with a high mortality rate, and a variable and nonspecific clinical presentation. To detect the nonspecific signs and symptoms associated with this condition, several right ventricular (RV) echocardiographic parameters have been proposed as practical marker.METHODSThis cross-sectional study was performed on 93 patients with PTE diagnosed by computed tomography (CT) angiography, and 57 patients with negative PTE based on CT angiography. During the experiment, all patients underwent both transthoracic echocardiography (TTE) and multi-slice CT pulmonary angiography. Transthoracic echocardiography measurements were obtained as patients went through both experimental procedures. These measurements were later compared between the patients with and without PTE.RESULTSTricuspid annulus plain systolic excursion (TAPSE) (1.65 ± 0.09 vs. 2.00 ± 0.08 cm, P < 0.001) and left ventricular (LV) end-diastolic diameter (4.54 ± 0.26 vs. 5.40 ± 0.24 cm, P < 0.001) were significantly lower in patients with PTE as compared to patients without it. Whereas, RV end-diastolic and end-systolic diameters at the papillary muscle levels (3.41 ± 0.09 vs. 3.02 ± 0.12 cm, and 2.48 ± 0.08 vs. 2.16 ± 0.06 cm, respectively, P < 0.001 for both), and tricuspid valve (TV) annulus tissue Doppler imaging (TDI) measurements (6.02 ± 0.10 vs. 5.78 ± 0.14, P < 0.001) were significantly greater in patients with PTE. On the other hand, no significant difference was found between the two groups of patients regarding pulmonary artery pressure (PAP) (P = 0.416), and RV fractional shortening (P = 0.157). Moreover, our results indicated that RV/LV (cut-off point: 0.6898) had high sensitivity (93.5%), specificity (100%), positive predicting value (PPV) (100%), and negative predicting value (NPV) (90.4%) in diagnosing PTE.CONCLUSIONTTE may be valuable as a substitute diagnostic method for patients with PTE. This technique may also assist in detecting the severity of the illness, by evaluating RV/LV in cut-off point of 0.6898.

Comparing the Performance of Tissue Doppler versus Left Atrial Strain in Predicting Left Ventricular End Diastolic Pressure in Patients with Different Left Ventricular Ejection Fractions

Background:Early trans-mitral inflow velocity and mitral annular tissue Doppler imaging (E/Em ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However, E/Em ratio has a significant gray zone among patients with severely impaired ejection fraction. Speckle tracking echocardiography (STE) was recently proposed as an alternative surrogate to estimate LV filling pressures. This study aimed at assessing performance of tissue Doppler parameters and left atrial global longitudinal strain as non-invasive surrogates for LV filling pressures and comparing accuracy of these two parameters across different striae of LVEF. Methods: A total of 96 patients with sinus rhythm and different ejection fraction who divided into four groups of 24 patients each according to their EF(>55%, 45–54%, 30–44%, and <30%), had an invasive measurement of the LV pressure. Both medial and lateral E/Em ratio were measured in all subjects by 2D Tissue Doppler, peak atrial longitudinal strain (PALS) and Peak atrial contraction strain (PACS) were obtained by averaging all segments measured in the 4-chamber. Results: Significant Correlation between global PALS and invasive LVEDP in all groups (r = 0.70 P < 0.000), While Lateral E/E’ shows significant correlation only in two groups; preserved and mildly impaired EF (r=0.42 P=0.023, r=0.439 p-0.032; respectively) Conclusion:In patients with preserved or mildly reduced LV ejection fraction, global PALS and Lateral E/E’ ratio presented good correlations with LVEDP. In patients with moderate or severe reduction of EF, E/E’ ratio correlated poorly with invasively measured LV filling pressures. Global PALS provided an overall better estimation of LV filling pressures.

Detecting impaired myocardial relaxation in sepsis with a novel tissue Doppler parameter (septal e\u2032/s\u2032)

BackgroundLeft ventricular diastolic dysfunction is associated with mortality outcomes in severe sepsis and septic shock. There are ongoing issues with diagnosing diastolic dysfunction in this cohort, partly owing to the poor applicability of traditional parameters in the hyperdynamic circulation. In this feasibility study, we sought to assess the utility of a novel parameter (septal e′/s′) to identify diastolic dysfunction in patients with severe sepsis and septic shock who had normal systolic function against the 2016 American Society Echocardiography and European Association of Cardiovascular Imaging (ASE/EACI) guidelines on diastolic dysfunction.MethodsIn this prospective observational pilot study, patients identified as having severe sepsis and septic shock underwent transthoracic echocardiography on day 1 and day 3 of their intensive care unit admission. In patients with normal systolic function, septal e′/s′ was calculated using the peak modal velocity of the s′ compared with the e′ from the septal annulus tissue Doppler imaging and compared with their diastolic grade according to the 2016 ASE/EACI guidelines on diastolic dysfunction.ResultsOn day 1 of admission, 44 of 62 patients with severe sepsis and septic shock had normal systolic function. There was a strong association of those with diastolic dysfunction having a reduced septal e′/s′ compared with patients with normal diastolic function (AUC 0.91). A similar relationship was seen with patients who had indeterminate diastolic dysfunction. On day 3, 37 patients had normal systolic function. Again, there was a strong association of those with diastolic dysfunction and a reduced septal e′/s′ (AUC 0.95).ConclusionsA reduction in septal e′/s′ may indicate diastolic dysfunction in patients with severe sepsis and septic shock who have normal systolic function. As opposed to limited traditional measures of diastolic dysfunction, it is applicable in those with hyperdynamic systolic function.

Study of left ventricular diastolic function in patients with DDD pacemaker implantation for sick sinus syndrome during atrioventricular conduction and right ventricular apex pacing mode

Objective To analyze the left ventricular (LV) diastolic function parameters of patients with sick sinus syndrome (SSS) and DDD pacemaker implantation during atrioventricular conduction (AVC) and right ventricular apex pacing (RVAP) mode. Methods Forty-six consecutive patients with SSS who had undergone DDD pacemaker implantation were studied. Fifty volunteers were selected as control group.Changing from AVC to RVAP mode, the acute effect on echocardiographic left ventricular diastolic function parameters, including mitral inflow PW parameters, mitral annulus tissue Doppler imaging parameters, left atrial volume index, and LV/apical/basal untwist parameters were measured. And all subjects were classified into normal diastolic function or three degrees of LV diastolic dysfunction. Results Compared with control group, both AVC and RVAP mode of patients with DDD pacemaker implantation resulted in the worsening of LV diastolic function as shown by (1) prolonged deceleration time of E wave, decreased descending slope of E wave, as well as decreased early diastolic velocity at the septal mitral annulus, (2) the decrease of LV/basal/apical untwist velocity, (3) the increase in the degree of diastolic dysfunction. Conclusions In patients with DDD pacemaker implantation, both AVC and RVAP mode are associated with the deterioration of LV diastolic function, which is particularly obvious in RVAP mode. Key words: Echocardiography; Cardiac pacemaker, artificial; Ventricular function, left

Epicardial Fat as a Contributing Factor to Diastolic Dysfunction

Background: As one of forces extrinsic to the myocardium, we hypothesized that epicardial fat may contribute to diastolic dysfunction. The objective of this study was to evaluate epicardial fat as a contributing factor to diastolic function. Methods: Two hundred and twenty-one patients without significant arrhythmia, left ventricular hypertrophy, significant valvular disease, decreased left ventricular systolic function, or coronary artery disease were studied. Epicardial fat thickness on the free wall of the right ventricle was measured at end-diastole from the parasternal long-axis views of 3 cardiac cycles. Diastolic function was evaluated using the left atrium volume index, mitral inflow parameters (E, A, E/A, DT [deceleration time]) and mitral annular tissue-Doppler imaging parameters (E’, A’, E/E’). Results: Two hundred and twenty-one patients were divided into 2 groups according to diastolic pattern (normal versus abnormal mitral inflow pattern). There were significant differences in epicardial fat thickness (0.31±0.11 mm vs. 0.48±0.2 mm; P<0.001). Epicardial fat thickness was significantly correlated with a high E/E’ (r=0.395, P<0.001) and high left atrium volume index (r=0.230, P=0.005). Multiple linear regression showed that epicardial fat thickness (β=0.250, t=2.756, P=0.005), left atrium volume index (β=0.273, t=3.270, P=0.007), and A (β=0.454, t=4.722, P=0.0001) were significant predicting factors for E/E’, whereas clinical parameters such as age, sex, hypertension, diabetes, metabolic syndrome, and high density lipoprotein cholesterol had no statistical significance. Conclusion: Our study showed that epicardial fat thickness is significantly related to diastolic dysfunction.

The Short-Term Effects of Ketogenic Diet on Cardiac Ventricular Functions in Epileptic Children

ObjectiveOur primary aim was to determine the short-term effects of a ketogenic diet on cardiac ventricular function in patients with refractory epilepsy. MethodsThirty-eight drug-resistant epileptic patients who were treated with a ketogenic diet were enrolled in this prospective study. Echocardiography was performed on all patients before beginning the ketogenic diet and after the sixth month of therapy. Two-dimensional, M-mode, color flow, spectral Doppler, and pulsed-wave tissue Doppler imaging measurements were performed on all patients. ResultsThe median age of the 32 patients was 45.5 months, and 22 (57.8%) of them were male. Body weight, height, and body mass index increased significantly at the sixth month of therapy when compared with baseline values (P < 0.05). Baseline variables assessed by conventional M-mode echocardiography showed no significant difference at month 6 (P > 0.05). Doppler flow indices of mitral annulus and tricuspid annulus velocity of patients at baseline and month 6 showed no significant differences (P > 0.05). Tricuspid annular E/A ratio was lower at month 6 (P < 0.05). Although mitral annulus tissue Doppler imaging studies showed no significant difference (P > 0.05), there was a decrease in Ea velocity and Ea/Aa ratio gathered from tricuspid annulus at month 6 compared with baseline (P < 0.05). ConclusionA 6-month duration ketogenic diet does not impair left ventricular functions in children with refractory epilepsy; however, it may be associated with a right ventricular diastolic dysfunction.

Diastolic function in paced children with cardiac defects: septum vs apex.

In children with structural congenital heart disease (CHD), the effects of chronic ventricular pacing on diastolic function are not well known. On the other hand, the beneficial effect of septal pacing over apical pacing is still controversial.The aim of this study was to evaluate the influence of different right ventricular (RV) pacing site on left ventricular (LV) diastolic function in children with cardiac defects.Twenty-nine pediatric patients with complete atrioventricular block (CAVB) and CHD undergoing permanent pacing were prospectively studied. Pacing sites were RV apex (n = 16) and RV septum (n = 13). Echocardiographic assessment was performed before pacemaker implantation and after it, during a mean follow‑up of 4.9 years.Compared to RV septum, transmitral E-wave was significantly affected in RV apical pacing (95.38 ± 9.19 vs 83 ± 18.75, p = 0.038). Likewise, parameters at the lateral annular tissue Doppler imaging (TDI) were significantly affected in children paced at the RV apex. The E´ wave correlated inversely with TDI lateral myocardial performance index (Tei index) (R2= 0.9849, p ≤ 0.001). RV apex pacing (Odds ratio, 0.648; confidence interval, 0.067-0.652; p = 0.003) and TDI lateral Tei index (Odds ratio, 31.21; confidence interval, 54.6-177.4; p = 0.025) predicted significantly decreased LV diastolic function.Of the two sites studied, RV septum prevents pacing-induced reduction of LV diastolic function.

(843) - Is Doppler Echocardiography Useful for Estimating Ventricular Filling Pressures in Pediatric Heart Transplant Recipients?

Left ventricular (LV) E/E’ ratio - the ratio of mitral inflow and annular tissue Doppler imaging (TDI) velocities- is accepted as a surrogate for LV filling pressure in adults but has performed poorly in children. We hypothesized that transforming raw Doppler velocities into z-scores using pediatric normative data will improve the reliability of echocardiographic measures to estimate LV filling pressure in pediatric heart transplant (HT) recipients. All echocardiograms with TDI performed within 24 hours of a heart catheterization during 2005-2011 were identified (N=751 studies in 122 HT recipients, median 6/pt). Age-based normative values in 380 healthy children were used to transform biventricular inflow and TDI velocities into z-scores. Multivariable generalized estimating equation models - which account for multiple studies in individual patients - were developed to relate mitral inflow and TDI velocities to pulmonary capillary wedge pressure (PCWP). A similar analysis was performed for mean right atrial pressure (RAP) using right ventricular (RV) Doppler velocities. The median age of the study cohort at first evaluation was 13.9 yrs (IQR 6.4-16.8 yrs). The median duration between HT and the first study was 1.9 yrs (IQR 0.1-6.4 yrs). Although LV E/E’ ratio was associated with PCWP in univariate analysis (R2 =0.11, P<0.001), the final multivariable model for PCWP included mitral inflow E and LV S’ velocities (R2=0.17, P<0.001) but not LV E/E’ ratio.Using z-scores for mitral E and LV S’ velocities modestly improved the model for estimating PCWP (R2= 0.20, P<0.001) whereas LV E/E’ z-score ratio was not significant. A multivariable model for RAP included RV E’, RV A’ and septal A’ velocities (R2=0.11, P<0.001) but not RV E/E’ ratio. Transforming these velocities to z-scores did not strengthen the association. There is only a modest association between Doppler echocardiography velocities and PCWP (or RAP) in pediatric HT recipients which is not improved by using z-scores for LV E/E’ ratio or other velocities. Cardiac catheterization retains its value in pediatric HT recipients for accurate assessment of LV and RV filling pressures in clinical care.

Tissue Doppler Imaging Findings Including Prominent S Wave in Patients With Mitral Valve Prolapse Syndrome

Background: Mitral valve prolapse (MVP) is allied to a variety of echocardiographic and pathologic findings, not least courtesy of the advent of novel and stringent echocardiographic criteria. MVP enjoys definite and clear-cut characteristics and is, as such, a fertile ground for research. Tissue Doppler imaging (TDI) is a relatively new imaging technique, and there is currently a dearth of information on this modality in patients with MVP syndrome. Objectives: We aimed to evaluate the findings of TDI in MVP syndrome. Patients and Methods: Seventy-five patients with MVP syndrome and 50 normal individuals as the control group were evaluated. The general characteristics and echocardiographic findings, especially TDI results, were evaluated and compared between the two groups. Mitral annular TDI velocities (Sm, Em, and Am) were measured at the lateral corner of the MV in the apical four-chamber view of transthoracic echocardiography. Results: Seventy-five patients (48 females) at a mean age of 26.5 ± 9.4 years and 50 individuals (32 females) at a mean age of 27.1 ± 8.3 years were enrolled in the study. As the important results of our study, Sm wave was much more prominent and much higher in the MVP group (P = 0.00); Em was lower (P = 0.00) and Am was slightly higher (P = 0.12). Furthermore, the E waves of MV inflow for the MVP and control groups were similar and E/Em was significantly higher in the MVP group (P = 0.00); taken together with a higher left atrial volume in this group, this finding revealed a relatively higher left ventricular end-diastolic pressure. Conclusions: Sm wave in TDI is prominent and significantly high in MVP syndrome. Also, our study showed some degree of diastolic dysfunction in MVP patients.

Risk of Death and Need for Transplantation in Chronic Pulmonary Hypertension

BackgroundEcho-Doppler parameters that exemplify right ventricular (RV) outflow dynamics and measures of annular tissue Doppler imaging to assess left ventricular (LV) and RV diastolic function, known to be affected in chronic pulmonary hypertension (cPH), have never been studied to determine if they could be predictive of mortality or need for transplantation 1-year after follow-up. MethodsNumerous echo-Doppler parameters of RV and LV performance were recorded from 120 patients. This patient population was divided into 3 groups. Group I had no PH, group II had cPH but no documented death or need for either lung or heart transplantation, at 1-year follow-up after their initial echocardiogram whereas group III had cPH and patients had either died or required heart and/or lung transplantation during the same time period. ResultsAnalysis of variance was first used to identify which echo-Doppler variables were significant among the studied groups. A logistic regression analysis was then performed to identify predictive variables of the occurrence death and need for transplantation. Finally, a multiple regression analysis was used between groups II and III to identify which echo-Doppler variables were most useful in identifying severe cPH patients at risk of the prespecified events. ConclusionsEven though older patients with worse RV fractional area change might be considered at risk of worse prognosis in patients with severe cPH, only a low mitral annular early diastolic velocity was useful in identifying which of those individuals were at highest risk of death or in need of transplantation.

Mechanism of exertional dyspnea in high output states: Is diastolic dysfunction a culprit? newer insights from doppler echocardiography

Background: The underlying mechanism of cardiac failure in high output states has not been clearly understood. It is well known that left ventricular systolic functional indices are usually preserved. So, what causes the symptoms of cardiac failure?. We analysed the LV diastolic parameters in some of the common high output states Aim: The aim of this study was to evaluate Left Ventricular (LV) diastolic function in various high output states. Study population: Comprising 185 patients, mean age -25 (20-30) years, of various high output states such as pregnancy 2nd trimester (24-28 wks), 3rd trimester (32-36 wks), Chronic kidney disease patients with patent arterio-venous fistula, Hyperthyroidism, Anemia with hemoglobin levels of 6-8 gm%, patients with normal left ventricular systolic function (EF 58-65%),functional class II or III were included in our study.Patients with co-morbid states fused trans-mitral inflow E/A velocities and arrhythmias were excluded. Methods: Echocardiographic evaluation of all patients was done using Philips HD7XE machine in our Echo lab. Diastolic function was assessed using conventional trans-mitral inflow pattern, Pulmonary venous flow, and mitral annular tissue Doppler imaging. Results: Results are shown in Table 1. View this table: Table 1 Conclusion: Diastolic LV function is relatively well preserved in most patients with physiologic high output states and it tends to get affected in pathologic high output states. It is likely that symptoms which suggest cardiac failure in some of these patients are not attributable to cardiac functional impairment as such. It is possible the symptoms of cardiac failure in high output states simply reflect hyper functioning heart due to increased metabolic demands.