Atrial Contraction Wave Research Articles

Correlation between nonalcoholic fatty liver disease and left ventricular diastolic dysfunction in non-obese adults: a cross-sectional study

Background and aimsNon-alcoholic fatty liver disease (NAFLD) is associated with a greater risk of developing cardiovascular disease and have adverse impacts on the cardiac structure and function. Little is known about the effect of non-obese NAFLD upon cardiac function. We aimed to compare the echocardiographic parameters of left ventricle (LV) between non-obese NAFLD group and control group, and explore the correlation of non-obese NAFLD with LV diastolic dysfunction.Methods and resultsIn this cross-sectional study, 316 non-obese inpatients were enrolled, including 72 participants with NAFLD (non-obese NAFLD group) and 244 participants without NAFLD (control group). LV structural and functional indices of two groups were comparatively analyzed. LV diastolic disfunction was diagnosed and graded using the ratio of the peak velocity of the early filling (E) wave to the atrial contraction (A) wave and E value. Compared with control group, the non-obese NAFLD group had the lower E/A〔(0.80 ± 0.22) vs (0.88 ± 0.35), t = 2.528, p = 0.012〕and the smaller LV end-diastolic diameter〔(4.51 ± 0.42)cm vs (4.64 ± 0.43)cm, t = 2.182, p = 0.030〕. And the non-obese NAFLD group had a higher prevalence of E/A < 1 than control group (83.3% vs 68.9%, X2 = 5.802, p = 0.016) while two groups had similar proportions of LV diastolic dysfunction (58.3% vs 53.7%, X2 = 0.484, p = 0.487). Multivariate logistic regression analysis showed that non-obese NAFLD was associated with an increase in E/A < 1 (OR = 6.562, 95%CI 2.014, 21.373, p = 0.002).ConclusionsNon-obese NAFLD was associated with decrease of E/A, while more research will be necessary to evaluate risk of non-obese NAFLD for LV diastolic dysfunction in future.

The correlation between serum ferritin levels and impaired heart function in children with transfusion dependent thalassemia

Background: Paediatric patients with transfusion dependent thalassemia require regular lifelong red cell transfusions. Blood transfusions increase the risk of iron overload, which can lead to cardiac hemosiderosis. Serum ferritin can be a parameter for evaluating systemic hemosiderosis. Objective: To evaluate the correlation between serum ferritin levels and impaired heart function in children with transfusion dependent thalassemia Methods: A cross sectional study was conducted with transfusion-dependent thalassemia who attended a cardiology and hemato-oncology outpatient clinic from January to December 2018 and had undergone more than 10 transfusion periods. Serum ferritin levels were taken from the mean of 3 measurements before echocardiography. Echocardiography examination was performed by a cardiologist using a 3D Doppler tool to evaluate ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE) and E / A ratio by calculating the initial diastole (E wave) and atrial contraction (wave A). Data analysis used the Spearman correlation with p &lt;0.05. Results: There were 45 children with a median age of 10 (2-17) years and had received a median of 18 (10-51) blood transfusions. The mean serum ferritin level was 4,321 (1,168-15,233) ng / mL. Blood transfusion frequency was associated with an increase in serum ferritin (rho 0.74, P &lt;0.005). From echocardiography examination, approximately 3/45 children had a feature of dilated cardiomyopathy. The mean value of EF 70 (SD 14.32), TAPSE 1.97 (SD 0.57) cm and an E / A ratio 1.68 (SD 0.46). Serum ferritin was negatively correlated with the ejection fraction (rho = -0.78, P &lt;0.001), TAPSE (rho = -0.65, P &lt;0.001) but positively correlated with the E / A ratio (rho = 0.67, P &lt;0.001). Conclusion: Paediatric patients with TDT have decreased cardiac systolic and diastolic function, and serum ferritin correlates with the decreased cardiac function.

Carvedilol improves left ventricular diastolic dysfunction in patients with transfusion-dependent thalassemia.

Background:Iron overload cardiomyopathy is the most common cause of death in patients with transfusion-dependent thalassemia.Aim:The aim of this study was to determine the efficacy of carvedilol treatment in patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction.Methods:Eighteen patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction were enrolled. All patients had normal left ventricular systolic function and were given carvedilol with the target dose of 0.8 mg/kg/day. Ventricular function and the level of cardiac iron were assessed by echocardiography and magnetic resonance imaging at 0, 3, and 6 months.Results:The median age of the patients was 19 years (range 13–25 years). Four patients had severe left ventricular Grade III diastolic dysfunction and fourteen patients had Grade II diastolic dysfunction. The grade of left ventricular diastolic dysfunction was improved at 3 months after the carvedilol treatment. The Doppler parameters, including pulmonary vein atrial reversal velocity, pulmonary vein atrial reversal duration, and the difference of pulmonary vein atrial reversal and the mitral valve atrial contraction wave duration at 3 months after the carvedilol treatment, were significantly lower than these parameters before the treatment.Conclusions:Among patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction without systolic dysfunction, treatment with carvedilol for 3 months was associated with improvement in Doppler parameters of left ventricular diastolic function. However, this finding and its clinical significance need to be confirmed in further double-blind controlled studies.

Atrial Function Assessed by Speckle Tracking Echocardiography Is a Good Predictor of Postoperative Atrial Fibrillation in Elderly Patients.

Advanced age is an independent predictor of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass surgery. We evaluated whether left atrial (LA) dysfunction assessed by strain contributes to identifying elderly patients prone to POAF. Case-control study of 70 subjects undergoing coronary artery bypass surgery. Clinical and laboratory characteristics were recorded at baseline and 72 hours after surgery. Echocardiography was performed during the preoperative period; LA dimensions and deformation by strain (systolic wave [LASs]) as well as strain rate (systolic wave [LASRs] and atrial contraction wave [LASRa]) were assessed. Postoperative atrial fibrillation occurred in 38.5% of patients within the first 72 hours after surgery (28.5% of the younger vs. 48.6% of the older group). Baseline and postoperative inflammatory markers as well as total surgical and aortic clamp time were similar between groups. LA function was markedly impaired in subjects with POAF. Age correlated with LASs, LASRs, and LASRa. These associations remained consistent when subjects 75 years or older were considered separately. Both LASs and LASRa for patients with or without POAF, respectively, were significantly impaired in elderly subjects with POAF. Multivariate analysis provided further evidence that both LASs and age are independent predictors for POAF. Age-related changes in atrial function preceding atrial dilation are evident only upon LA strain analysis. LA strain impairment is an independent predictor of POAF irrespective of age and may serve as a surrogate marker for biological processes involved in establishing the substrate for POAF.

Fetal pulmonary venous Doppler flow patterns in hypoplastic left heart syndrome

To discuss the value of fetal pulmonary venous Doppler flow patterns in hypoplastic left heart syndrome (HLHS). Forty-six HLHS and 180 normal singleton fetuses at 24+0 to 37+6 weeks of gestation were enrolled in this study. The blood flow of pulmonary vein (PV) was detected by color Doppler ultrasound. The systolic wave of ventricle (S-wave), diastolic wave of ventricle (D-wave), atrial contraction wave (A-wave) and S/D ratio of PV were measured. The statistical difference in the above parameters between HLHS and normal fetuses was compared. The diagnosis was also confirmed by autopsy in still birth or postnatal follow-up when the baby was alive. The PV blood flow in HLHS fetuses had a high possibility of reversed A wave, and the velocity of S wave and S/D ratio were higher than the matched normal controls (P<0.001). There were 3 types of PV blood flow patterns among all fetuses with HLHS. Both the cases with right to left shunt through foramen ovale (FO) and the cases with restricted left to right shunt at FO showed the triphasic patterns of PV with antegrade S wave, D wave and retrograde A wave. However, the latter had a higher velocity of retrograde A wave (P<0.001), lower D wave (P<0.001), and obviously elevated S wave and S/D ratio (P<0.001). The cases with intact interatrial septum showed short and apparent pulsatile back and forth blood flow in the PV, which displayed as absence of D wave. The 3 types of PV blood flow patterns in the fetuses with HLHS reflect the severity of hypertension in the left atrium, which is extremely vital for the prognosis and the perinatal treatment plan.

Fluid structure interaction (FSI) simulation of the left ventricle (LV) during the early filling wave (E-wave), diastasis and atrial contraction wave (A-wave)

In this paper, the hemodynamic characteristics inside a physiologically correct three-dimensional LV model using fluid structure interaction scheme are examined under various heart beat conditions during early filling wave (E-wave), diastasis and atrial contraction wave (A-wave). The time dependent and incompressible viscous fluid, nonlinear viscous fluid and the stress tensor equations are coupled with the full Navier-Stoke's equations together with the Arbitrary Lagrangian-Eulerian and elasticity in the solid domain are used in the analysis. The results are discussed in terms of the variation in the intraventricular pressure, wall shear stress (WSS) and the fluid flow patterns inside the LV model. Moreover, changes in the magnitude of displacements on the LV are also observed during diastole period. The results obtained demonstrate that the magnitude of the intraventricle pressure is found higher in the basal region of the LV during the beginning of the E-wave and A-wave, whereas the Ip is found much higher in the apical region when the flow propagation is in peak E-wave, peak A-wave and diastasis. The magnitude of the pressure is found to be 5.4E2 Pa during the peak E-wave. Additionally, WSS elevates with the rise in the E-wave and A-wave but the magnitude decreases during the diastasis phase. During the peak E-wave, maximum WSS is found to be 5.7 Pa. Subsequent developments, merging and shifting of the vortices are observed throughout the filling wave. Formations of clockwise vortices are evident during the peak E-wave and at the onset of the A-wave, but counter clockwise vortices are found at the end of the diastasis and at the beginning of the A-wave. Moreover, the maximum magnitude of the structural displacement is seen in the ventricle apex with the value of 3.7E-5 m.

Left Atrial Appendage Resection Versus Preservation During the Surgical Ablation of Atrial Fibrillation

Left atrial appendage (LAA) resection during the Maze procedure may decrease thromboembolic risks, but its preservation may improve left atrial contractile function. This study compared the clinical effects of LAA resection and preservation after the Maze procedure. A retrospective review was made of 379 patients (mean age 53.3 ± 12.6 years, 244 females) who underwent the cryo-Maze procedure in conjunction with mitral surgery from 1999 to 2011. The LAA was resected in 187 patients (resection group) but preserved in 192 patients (preservation group). Outcomes were compared using a propensity score study design based on 20 baseline characteristics to obtain well-matched patient pairs. Propensity score matching yielded 119 pairs of patients in whom there were no significant differences in baseline profiles between the two groups. During a mean follow-up of 3.1 ± 2.8 years, there were 16 deaths, 6 cases of stroke, and 39 cases of atrial fibrillation recurrence. There were no significant differences in stroke-free survival (p = 0.88) and freedom from AF while off antiarrhythmic drugs (p = 0.46) between the two groups. On serial echocardiographic assessments, patients in the preservation group showed a higher transmitral A-wave velocity (peak atrial contraction wave velocity; p = 0.47, 0.020, and 0.001 at 3, 6, and 12 months, respectively) and lower E/A ratio (peak early filling wave [E-wave] velocity / A-wave velocity; p = 0.34, 0.065, and 0.001 at 3, 6, and 12 months, respectively) at each timepoint compared with the resection group. Preservation of the LAA during the Maze procedure resulted in similar clinical and rhythm outcomes, but LA contractile function superior to that of LAA resection.

The effects of spironolactone on atrial remodeling in patients with preserved left ventricular function after an acute myocardial infarction

Atrial remodeling is an important part of cardiac remodeling after acute myocardial infarction (AMI). The aim of this study was to evaluate the effect of spironolactone on atria in patients with preserved left ventricular (LV) functions after AMI by using two-dimensional and tissue Doppler imaging techniques (TDI). The study consisted of 110 patients with AMI, successfully revascularized with percutaneous coronary intervention, ejection fraction greater than or equal to 40%, and Killip class I-II. Patients were randomized into two groups: conventional therapy (n=55) and additional spironolactone of 25 mg/day with standard conventional therapy (n=55). Echocardiography was performed in the first 48-72 h of AMI and during 6 months of follow-up. Left atrial volume index and emptying fraction were obtained. The peak regional atrial contraction velocity, the time between the onset of p-wave on the monitor ECG and the onset, peak, and the end (TE) of the atrial contraction wave on the tissue Doppler technique curve were measured. The left atrial volume index and left atrium (LA) dimensions did not significantly change in either group. In the spironolactone group, left atrial emptying fraction increased compared with both baseline value (from 53.0 ± 0.16 to 57.0 ± 0.13 P=0.011) and conventional therapy group (from 50.0 ± 0.17 to 47.0 ± 0.16, P=0.013). The atrial contraction velocity did not change but the LA-TE, interatrial septum-TE, and right atrium-TE were prolonged in the conventional therapy group. Additional spironolactone therapy provided a little benefit on LA remodeling and atrial electromechanic properties in patients with AMI and preserved LV functions.

Erratum to: Prenatal Diagnosis and Management of Fetal Long QT Syndrome

In the online and print versions of this article published previously, Fig. 2 was presented incorrectly. In the figure of the pulsed Doppler echocardiogram depicting a second degree A-V block, there were interchanged signs of short early deceleration time of mitral valve flow (arrows) and atrial contraction wave (A) in beats with preserved atrioventricular conduction. In the correctly annotated image, short early deceleration time of mitral valve flow (arrows) is followed by atrial contraction wave (A). The corrected figure and caption appear below.

Diastolic dysfunction and atrial fibrillation

Isolated diastolic heart failure (DHF) is defined as heart failure with preserved left ventricular (LV) systolic function in the absence of valve disease. DHF is a clinical diagnosis confirmed by echocardiography and is presumed to be due to diastolic dysfunction (DD). DD is characterized by abnormalities in relaxation and/or distensibility (restriction) of the left ventricle (LV). DHF accounts for 30% to 50% of patients with heart failure and is an independent predictor of atrial fibrillation (AF) in the elderly. This paper will describe the diagnosis of DD in both sinus rhythm and AF as well report on agents used in the treatment of DHF and prevention of AF in DHF. DIAGNOSIS IN SINUS RHYTHM: Early DD is identified by Doppler determined mitral inflow measurements: The ratio of the peak velocity of the early filling (E) wave to the atrial contraction (A) wave, E/A is <1, the deceleration time (DT) is slow (>240 ms), the isovolumic relaxation period (IRP) is prolonged (>110 ms). In Moderate DD, the LV stiffens with elevated left atrial pressure resulting in "pseudonormal" filling pattern with E/A ratio >1. This is unmasked by pulmonary vein measurements with the systolic forward flow (S) being less than (approximately 50%) diastolic forward flow wave (D). Retrograde flow wave (A (R)) is increased >0.25 m/s. As the LV stiffens, restrictive features develop resulting in rapid early filling with E/A ratio >2, shortened DT <150 ms and IRP <60 ms. The A (R) wave is increased in amplitude >0.35 m/s and duration >30 ms. Early diastolic filling reflected by tissue Doppler determination of mitral annulus motion velocity (E') is reduced in DD. The E/E' ratio correlates well with filling pressures. DIAGNOSIS IN AF: Atrial contraction is absent and therefore measurements independent of atrial influence such as DT, IRP, E/E' ratio and S wave are used. THERAPY FOR DHF AND AF PREVENTION: While not well established, Treatment with ACE-inhibitors, angiotensin receptor blockers (ARBs) and aldosterone antagonists have shown objective improvement in DHF and ARBs have been found to decrease the incidence of AF. Candesartan decreases the incidence of AF in patients with symptomatic heart failure and preserved LV systolic function. There are ongoing studies of Irbesartan and spironolactone to evaluate their effect on DHF treatment. Diagnosis of DD is made by echocardiography in patients with sinus rhythm or in patients with AF. Randomized controlled trials in patients with DHF are under way. The treatment of DHF and AF prevention will continue to evolve.

Gestational Diabetes: A Condition of Early Diastolic Abnormalities in Young Women

Gestational diabetes mellitus (GDM) is not merely a temporary condition, but a harbinger of type 2 diabetes mellitus, hypertension, and atherosclerotic disease. We examined the effect of GDM on cardiac diastolic function. Diastolic function was evaluated by serial Doppler echocardiography with pulsed tissue Doppler imaging in 13 patients with GDM and 13 healthy pregnant women (control group) during the third trimester of pregnancy and after 8 weeks postpartum. Diagnostic criteria for GDM were those as recommended by the American Diabetes Association. Exclusion criteria were any disease or condition that could interfere with diastolic function. Measurements at both times in each group were compared by paired t tests and changes of patients with diabetes were compared with those in control patients by unpaired t tests. There were no differences in age, left ventricular mass, or systolic function between groups. The Doppler parameters that showed significant difference between groups were higher atrial contraction wave (A wave) (P = .008) and lower rapid filling wave (E)/A ratio (P = .006) in diabetic group, on both occasions. Tissue Doppler parameters showed a significant decrease in Em (P = .002) and early mitral annulus velocity (Em)/late mitral annulus velocity (Am) (P = .008) in diabetic group on both occasions, and the Am wave remained increased only in the diabetic group at postpartum. Patients with GDM showed a different diastolic function profile, suggesting a mild degree of diastolic abnormality. The persistence of some abnormalities postpartum corroborates our hypothesis of an early cardiovascular involvement in this group, enhancing the need of a close cardiovascular follow-up of these patients.

OC115: Intracerebral regional distribution of blood flow in response to acute hypoxemia in growth‐restricted human fetuses

Objective: The atrial contraction wave is the single most important component of the ductus venosus (DV) indices used in predicting acidosis and adverse outcome. Based on the assumption that some pre-terminal changes in cardiac compliance and performance are rather reflected in the systolic and early diastolic components of the DV waveform, we aimed to establish and test new indices suitable for clinical use. Methods: DV velocities of 381 low-risk pregnancies were used to establish reference ranges for systolic pulsatility [DV-SPuls = (systolic peak − systolic nadir)/systolic peak] and early diastolic pulsatility [DV-DPuls = (diastolic peak − systolic nadir)/diastolic peak]. The DV-SPuls and DV-DPuls were determined in 123 cases where the DV Doppler recording was done ≤2 days before Cesarean section and where arterial cord pH and base excess (BE) were available at delivery, and in 15 cases of intrauterine fetal death (IUD). Power-transformation was used to achieve normality and fractional polynomial regression to calculate reference ranges, and SD-score statistics to assess deviation from the reference means. P < 0.05 was considered significant. Results: Arterial cord pH < 7.15 (n = 12), BE <−8.7 (n = 10), and particularly IUD (n = 15) were associated with increased DV-SPuls and DV-DPuls (overall p < 0.0001, and no overlap of 95%CI) when compared with the reference population. The DV-SPuls and DVDPuls were particularly high in cases with IUD (means were 2.4 and 3.1 SDs above means for the reference population) and also significantly higher than in fetuses that had arterial cord pH < 7.15 and BE <−8.7 (no overlap of 95%CI). Conclusions: Changes in the ductus venosus waveform during systole and early diastole are linked to alterations in acid base status at birth and intrauterine death. Augmented pulsations in this part of the DV wave may give valuable additional information on pre-terminal deterioration of the fetal circulation.

OC114: Ductus venosus systolic and early diastolic wave indices: new markers of pre‐terminal changes in cardiac function

Objective: The atrial contraction wave is the single most important component of the ductus venosus (DV) indices used in predicting acidosis and adverse outcome. Based on the assumption that some pre-terminal changes in cardiac compliance and performance are rather reflected in the systolic and early diastolic components of the DV waveform, we aimed to establish and test new indices suitable for clinical use. Methods: DV velocities of 381 low-risk pregnancies were used to establish reference ranges for systolic pulsatility [DV-SPuls = (systolic peak − systolic nadir)/systolic peak] and early diastolic pulsatility [DV-DPuls = (diastolic peak − systolic nadir)/diastolic peak]. The DV-SPuls and DV-DPuls were determined in 123 cases where the DV Doppler recording was done ≤2 days before Cesarean section and where arterial cord pH and base excess (BE) were available at delivery, and in 15 cases of intrauterine fetal death (IUD). Power-transformation was used to achieve normality and fractional polynomial regression to calculate reference ranges, and SD-score statistics to assess deviation from the reference means. P < 0.05 was considered significant. Results: Arterial cord pH < 7.15 (n = 12), BE <−8.7 (n = 10), and particularly IUD (n = 15) were associated with increased DV-SPuls and DV-DPuls (overall p < 0.0001, and no overlap of 95%CI) when compared with the reference population. The DV-SPuls and DVDPuls were particularly high in cases with IUD (means were 2.4 and 3.1 SDs above means for the reference population) and also significantly higher than in fetuses that had arterial cord pH < 7.15 and BE <−8.7 (no overlap of 95%CI). Conclusions: Changes in the ductus venosus waveform during systole and early diastole are linked to alterations in acid base status at birth and intrauterine death. Augmented pulsations in this part of the DV wave may give valuable additional information on pre-terminal deterioration of the fetal circulation.

Severe Stenosis of a Bovine Jugular Vein Graft in Pulmonary Position

The bovine jugular vein graft (Contegra, Medtronic Inc, Minneapolis, Minn) has been successfully used as vascular conduit for valve reconstruction in the last few years, generally in the pediatric population. Complications after implantation include thrombosis at the level of the conduit valve (especially in infants), pseudoaneurysm, and stenosis at the level of the distal anastomosis. A 29-year-old man presented with symptoms and signs of right-sided heart failure (ie, exercise intolerance, dyspnea, jugular vein distention, hepatomegaly, ascites, ankle edema). Two and a half years previously, he had undergone Ross procedure because of severe aortic regurgitation caused by intravenous drug abuse–related Staphylococcus aureus endocarditis. The 22-mm bovine jugular vein graft was implanted in pulmonary position. Transthoracic echocardiography revealed a severely stenotic graft at the distal anastomosis to the pulmonary trunk whereas the valve itself appeared normal (Figure 1, A). The supravalvular tissue overgrowth detected was suggestive of massive neointimal hyperplasia. Doppler analysis documented a maximal instantaneous systolic gradient of 105 mm Hg and a mean systolic gradient of 63 mm Hg (Figure 1, B) and color Doppler imaging confirmed flow acceleration at the level of the distal graft anastomosis (Figure 1, C). The patient underwent percutaneous balloon angioplasty and stent implantation (34-mm 8Zig Stent, Numed, Cornwall, Ontario, Canada). Transthoracic echocardiography performed the day of the procedure showed a well-expanded stent with a constant diameter across the graft (Figure 2, A). Doppler echocardiography documented a maximal instantaneous systolic gradient of 37 mm Hg and a mean systolic gradient of 23 mm Hg (Figure 2, B). The diastolic pressure gradient before the atrial contraction wave detected before stenting (Figure 1, B) vanished, indicating lowered

Utility of a Doppler-derived index combining systolic and diastolic performance (Tei index) for detecting hypoxic cardiac damage in newborns

The purpose of this study was to assess cardiac function of newborns with mild asphyxia by a Doppler-derived index combining systolic and diastolic performance (Tei index). We studied 20 preterm infants with mild asphyxia. A control group consisted of 20 gestational age-matched preterm infants without asphyxia. Echocardiograms were performed during the fourth and seventh days after birth. Peak velocities of an early filling wave (E) and an atrial contraction wave (A) were measured from the mitral inflow velocity profile and the ratio of peak E to A was calculated. Ejection time was measured from the left ventricular outflow Doppler signal. The sum of isovolumetric times was obtained by subtracting the ejection time from the interval between cessation and onset of mitral inflow. The index was the sum of isovolumetric times divided by ejection time. Ejection fraction was also calculated. The ratio of peak E to A and ejection fraction were the same in both groups. The myocardial performance index in patients with asphyxia was higher than that in patients without asphyxia. We concluded that patients with mild asphyxia have a mild cardiac dysfunction and this change can be detected by a myocardial performance index.

Venous pulsation in the fetal left portal branch: the effect of pulse and flow direction.

To determine whether the waveform in the left portal branch is reciprocal to the waveform found in the ductus venosus and umbilical vein due to difference in pulse direction compared to flow. Ten fetuses (gestational age, 18-33 weeks), six with intrauterine growth restriction, three with non-immune hydrops and one with sacrococcygeal teratoma, were examined using ultrasound imaging and pulsed Doppler. Techniques were adjusted to record simultaneously the waveform from neighboring sections of the veins, relate wave components to each other and determine degree of pulsatility. The corresponding vessel diameters were determined. ANOVA with t-test or Wilcoxon signed rank test was used to compare paired measurements. Pulsation in the left portal branch was noted in all fetuses. The pulsatility index was higher than in the umbilical vein (P = 0.005) and the diameter smaller (P = 0.001). In the left portal branch the atrial contraction wave appeared as a velocity peak while there was a nadir during ventricular systole. Simultaneous recordings showed that the waveform was reciprocal to that found in the ductus venosus and umbilical vein. In three cases an augmented pulsatility represented a pendulation of blood in the left portal branch with time-averaged velocity near zero. The velocity waveform recorded in the left portal vein is an inverse image of that in the ductus venosus, proving that pulse wave and blood flow run in the same direction in the left portal vein. Low compliance (i.e. small diameter) is probably a main reason for the high incidence of pulsation in this vein. Time-averaged velocity near zero recorded in three fetuses indicates that this area acts also as a watershed.

Usefulness of Doppler myocardial imaging for identification of mutation carriers of familial hypertrophic cardiomyopathy

Because myocyte dysfunction and disarray are early abnormalities in hypertrophic cardiomyopathy (HC), we tested if Doppler myocardial imaging (DMI) could identify systolic and diastolic dysfunction in mutation carriers (MC) (genotype positive patients without hypertrophy, defined as phenotype negative after conventional screening tests). In a single family with a missense mutation in the myosin binding protein C gene (Arg 502 Gln) we identified 5 MCs; these subjects were asymptomatic and had normal physical examination, normal electrocardiogram, treadmill stress test, ambulatory Holter electrocardiogram, and normal conventional M-mode, 2-dimensional, and Doppler echocardiography. In each patient we performed a DMI study and measured the peak velocities of the systolic (S), rapid filling (E), and atrial contraction (A) waves in the 4 sides of the mitral annulus, in 8 left ventricular segments (apical views), in the tricuspid annulus, and in 2 right ventricular segments. These data were compared with those from 10 normal volunteers matched for sex, age, and body surface. Compared with the normal volunteers, the MCs had lower left ventricular systolic velocities and higher right ventricular systolic velocities; lower diastolic rapid filling velocities; higher or similar atrial contraction velocities; reduced E/A; lower percentage of annular sides and segments with E/A >1 and lower average number of sides and/or segments with E/A >1 per patient; similar right ventricular rapid filling velocities; and similar or higher atrial contraction wave velocities. Thus, DMI detects important left and right ventricular annular and regional myocardial contraction and relaxation abnormalities independently of the presence of hypertrophy, in HC. These results show that DMI is more sensitive than conventional echocardiography and establishes a new and highly accurate method for the noninvasive screening of MCs of the disease.

Transoesophageal echocardiography in critically ill patients. A comprehensive approach

Transoesophageal echocardiography in critically ill patients. A comprehensive approach

Transoesophageal echocardiographic evaluation of ventricular function during transvenous defibrillator implantation.

Intraoperative testing and defibrillation threshold determination may jeopardise patients, scheduled for implantation of a cardioverter-defibrillator (ICD). The purpose of this study was the assessment of the influence of consecutive defibrillation attempts on left ventricular systolic and diastolic function by means of transoesophageal echocardiography (TEE). Eighteen patients with malignant ventricular arrhythmias that were resistant to antiarrhythmic drugs were monitored with TEE before, during and after implantation of a cardioverter-defibrillator. Left ventricular fractional area contraction as a measure of ejection fraction was assessed before and after each defibrillation attempt. Transmitral and right upper pulmonary venous flow parameters were evaluated before and after the whole implantation procedure. Adequate data were available in 14 patients during 4 consecutive attempts. No major alterations were observed in heart rate or fractional area contraction, measured at 30 s and 3 min after defibrillation. Overall, the ratio of early-to-late transmitral filling decreased significantly after the implantation procedure (from 0.91 +/- 0.12 to 0.82 +/- 0.14; P < 0.05). Systolic pulmonary venous flow velocity decreased from 0.49 +/- 0.11 to 0.41 +/- 0.10 m/s (P = 0.04); this decrease was observed in both groups. A significant increase of the atrial contraction wave (from 0.25 +/- 0.06 to 0.34 +/- 0.07 m/s; P < 0.03) was seen. Subdividing patients related to their precperative ejection fraction, a significant decrease of the early-to-late transmitral filling of the LV was revealed in patients with ejection fraction less than 35% (group 1). Also, a significantly lower systolic fraction of the pulmonary venous flow after ICD implantation in conjunction with a significantly longer diastolic flow time was shown in this patient group in comparison with patients with a preoperative ejection fraction of more than 35% (group 2). Defibrillation threshold testing of the ICD system changes LV inflow characteristics and impedes diastolic function of the left ventricle and may thus precipitate heart failure by this mechanism. No deleterious effects of threshold testing were observed with respect to fractional area contraction nor any deterioration of LV function was found in a clinically significant amount due to consecutive defibrillation attempts.

Influence of left atrial function on Doppler transmitral and pulmonary venous flow patterns in dilated and hypertrophic cardiomyopathy: Evaluation of left atrial appendage function by transesophageal echocardiography

Information regarding the relation of left atrial (LA) function to transmitral and pulmonary venous (PV) flow is limited. Using transesophageal echocardiography, we analyzed this relation in 23 patients with dilated cardiomyopathy (DCM) and 25 patients with hypertrophic cardiomyopathy (HCM). Left atrial appendage (LAA) function was assessed as a substitute for overall LA function. Transmitral and PV flow-velocity variables, the LAA emptying flow velocity (LAA-A), and the LAA ejection fraction (LAA-EF) were determined. Each patient group was divided into two subgroups with a normal (<15 mm Hg) or elevated (≥15 mm Hg) mean pulmonary wedge pressure (PWP). Transmitral and PV flow patterns as well as LA function were similar in the two subgroups with a normal PWP (11 patients with DCM and 14 patients with HCM). For the subgroups with an elevated PWP, however, the peak velocity ratio of the early filling wave (E) to atrial contraction wave (A) was higher in DCM patients ( n = 12) than in HCM patients ( n = 11) (2.1 ± 0.7 vs 1.3 ± 0.2; p < 0.01). This difference mostly resulted from a lower A velocity in the DCM group than in the HCM group (30 ± 10 cm/sec vs 43 ± 7 cm/sec; p < 0.05). In addition, the reverse flow velocity at atrial contraction in the PV was lower in the DCM group than in the HCM group (19 ± 8 cm/sec vs 37 ± 8 cm/sec; p< 0.01). These findings were associated with poorer LA systolic function in the DCM group (LAA-A, 35 ± 13 cm/sec vs 60 ± 11 cm/sec; LAA-EF, 37% ± 12% vs 55% ± 15%, p < 0.05, respectively). Our data suggest that a restrictive transmital flow pattern develops more easily in DCM than in HCM because LA dysfunction is present in DCM, and that LA contractility plays an important role in determining the atrial contraction wave of transmitral and PV flows with elevated LA pressure.