Color Tissue Doppler Imaging Research Articles

Thoracic and abdominal aortic dissection in a hypertensive hyperthyroid cat

Aortic dissection is an uncommon finding in both dogs and cats. The precise pathophysiological mechanisms responsible for the development of aortic dissection remain unclear. In humans, aortic dissection is usually secondary to another systemic disease, such as systemic arterial hypertension, an abnormality of connective tissues or a parietal trauma. This is a case of an aortic dissection in a hypertensive hyperthyroid cat, presenting with haemorrhagic pericardial effusion. The dissection affected both thoracic and abdominal aorta, with histopathological confirmation. This case is an example of the utility of both thoracic and abdominal ultrasound for the diagnosis of aortic dissection in cats and it highlights the importance of rigorous clinical examination. Aortic dissection should be considered in the differential diagnosis of pericardial effusion in cats. Further investigations are fundamental to understand how dissections develop and extend to achieve good clinical results.
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Do Maternal Heart Diseases Affect Fetal Cardiac Functions?

To investigate whether fetal cardiac function is affected by underlying heart disease in pregnant women. A total of 100 pregnant women who were ≥34 gestational weeks were included in the study, 40 in the maternal heart disease (MHD) group diagnosed with heart disease and 60 in the control group. All cardiac diseases in pregnant women were diagnosed preconceptionally and categorized according to the New York Heart Association (NYHA) classification system. Fetal cardiac functions of study groups were evaluated by M-mode, color tissue Doppler imaging (c-TDI), and pulsed wave Doppler. Tricuspid annular plane systolic excursion and myocardial performance index (MPI) values were significantly higher and isovolumetric relaxation time was prolonged in the MHD group. The MPI value was found higher in MHD group with NYHA Class II compared to those with NYHA Class I. No significant change in any of the fetal tricuspid annular peak velocity values measured by c-TDI in the MHD group. There were no differences in fetal cardiac functions and perinatal outcomes between pregnant women with acquired and congenital heart diseases. Patients in NYHA Class II had lower birth weight, 1st and 5th minute APGAR scores, and higher neonatal intensive care unit admission rates. Underlying heart diseases in pregnant women can cause alterations in the systolic and diastolic function of the fetal heart. High fetal MPI values detected in cardiac patients may indicate that cardiac pathologies during pregnancy affect fetal cardiac globular myocardial function. Cardiac pathologies that progress with restricted physical activity may cause changes in fetal cardiac function and may be associated with adverse perinatal outcomes.

Long-term safety of dietary salt: A 5-year ProspEctive rAndomized bliNded and controlled stUdy in healThy aged cats (PEANUT study).

High-salt diets promote urine dilution and decrease urolithiasis risk. Prospectively evaluate the safety of chronic high dietary salt intake (randomized controlled trial). Twenty research colony neutered, healthy aged cats (11.5 years [10.0-11.6], median [interquartile range]). Healthy cats were randomized to control or high-salt dry diets (sodium: 1.02 ± 0.16 [mean, SD] and 3.26 ± 0.30 g/Mcal metabolizable energy [ME], respectively; chloride: 2.26 ± 0.33 and 5.71 ± 0.28 g/Mcal ME, respectively), fed for up to 60 months. Assessments included CBC, plasma biochemistry, urinalysis, glomerular filtration rate (GFR), blood pressure, renal and cardiac (conventional Doppler and 2-dimensional color tissue Doppler) imaging, annually. Cats that died or were euthanized underwent necropsy. Diet effects over time were evaluated with linear mixed models. Follow-up duration (median [Interquartile range]) was similar between the control (38.7 months [28.6-48.2]) and high-salt group (51.4 months [45.7-59.0]). Diet had no significant effect on changes in GFR, blood pressure, plasma creatinine concentration, end-diastolic left ventricular (LV) wall thicknesses, LV internal diameters, LV systolic function, left atrial size, or systolic and diastolic Doppler variables. One control cat developed hypertension. One high-salt group cat developed persistent azotemia. Serial plasma biochemistry and urine specific gravity suggested early chronic kidney disease in 4 nonazotemic cats (2 per group), consistent with necropsy findings. In healthy aged cats, a commercial veterinary diet containing 3.26 ± 0.30 g/Mcal ME sodium was safe with regard to renal and cardiac function for up to 5 years.

Association between cardiac time intervals and incident heart failure after acute coronary syndrome

Abstract Background Cardiac time intervals are sensitive markers of myocardial dysfunction that predisposes to heart failure (HF). Color tissue Doppler imaging (TDI) curved M-mode is a reliable method for measuring cardiac time intervals. Purpose We aimed to investigate the association between cardiac time intervals and HF in patients with acute coronary syndrome (ACS). Methods This was a retrospective cohort study of 580 ACS patients treated with percutaneous coronary intervention (PCI). Patients underwent an echocardiography examination performed a median of two days after PCI. By echocardiography cardiac time intervals including isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET) were obtained by TDI curved M-mode and used to derive the myocardial performance index (MPI). The outcome was incident HF. Patients with prevalent at baseline HF were excluded from the analysis. Results The final study sample consisted of 387 patients, 73% were male, the mean age was 64 years, 76% of the ACS events were STEMI and LVEF and GLS were 42% and -13.1%, respectively. During follow-up (median 4.3, IQR:1.0-6.7 years), 140 (36%) developed HF. In unadjusted analyses, longer combined indexes were associated with a higher risk of HF (IVRT/ET: HR 1.24 (1.07-1.43), P = 0.003, per 0.1 increase) and (IVCT/ET: HR 1.44 (1.10-1.91), P = 0.010, per 0.1 increase), and so was higher MPI (HR 1.20 (1.08-1.34),P = 0.001, per 0.1 increase). In addition, shorter ET was also associated with higher HF risk (HR 1.13 (1.07-1.18), P<0.001 per 10ms decrease). MPI and IVCT/ET showed a curvilinear association with the outcome, whereas a linear association was observed for ET and IVRT/ET to the outcome (figure 1). After multivariable adjustment for cardiovascular risk factors, only MPI (HR 1.13 (1.01-1.27), P = 0.034), ET (HR 1.09 (1.01-1.17), P = 0.025), and IVCT/ET (HR1.37 (1.04-1.81), P = 0.023) remained significantly associated with HF. Of note, left ventricular ejection fraction (LVEF) significantly modified the association between ET and HF (p for interaction = 0.002), such that ET was associated with HF even in those with preserved LVEF (>40%) (HR 1.13 (1.02-1.24, P = 0.017, per 10ms decrease), but not in those with reduced LVEF (HR 1.02 (0.96-1.08), P = 0.56, per 10ms decrease). These findings also persisted after adjustment for cardiovascular risk factors. Conclusion Shortened ET, prolongation of combined indexes, and higher MPI were associated with an increased risk of incident HF. In addition, shortening of the ET was associated with an increased risk of HF in patients with preserved systolic function by LVEF.

Age- and sex-based normal reference ranges of the cardiac time intervals: the Copenhagen City Heart Study.

Color tissue Doppler imaging (TDI) M-mode can be used to measure the cardiac time intervals including the isovolumic contraction time (IVCT), the left ventricular ejection time (LVET), the isovolumic relaxation time (IVRT), and the combination of all the cardiac time intervals in the myocardial performance index (MPI) defined as [(IVCT + IVRT)/LVET]. The aim of this study was to establish normal age- and sex-based reference ranges for the cardiac time intervals. A total of 1969 participants free of cardiovascular diseases and risk factors from the general population with limited age range underwent an echocardiographic examination including TDI. The median age was 46years (25th-75th percentile: 33-58years), and 61.5% were females. In the entire study population, the IVCT was observed to be 40 ± 10ms [95% prediction interval (PI) 20-59ms], the LVET 292 ± 23ms (95% PI 248-336ms), the IVRT 96 ± 19ms (95% PI 59-134ms) and MPI 0.47 ± 0.09 (95% PI 0.29-0.65). All the cardiac time intervals differed significantly between females and males. With increasing age, the IVCT increased in females, but not in males. The LVET did not change with age in both sexes, while the IVRT increased in both sexes with increasing age. Furthermore, we developed regression equations relating the heart rate to the cardiac time intervals and age- and sex-based normal reference ranges corrected for heart rate. In this study, we established normal age- and sex-based reference ranges for the cardiac time intervals. These normal reference ranges differed significantly with sex.

Effects of pemafibrate on left ventricular diastolic function in patients with type 2 diabetes mellitus: a pilot study.

Diabetic cardiomyopathy (DCM) is characterized predominantly by diastolic dysfunction. The multiple mechanisms underlying DCM include altered energy substrate utilization. Recent studies indicate that PPARα plays an important role in the pathogenesis of lipotoxic cardiomyopathy. Pemafibrate is known to be a selective PPARα modulator (SPPARMα). We thus investigated the effects of pemafibrate on cardiac diastolic function in patients with type 2 diabetes. Seventeen patients with type 2 diabetes (T2D) and hypertriglyceridemia were screened and treated with pemafibrate at a dose of 0.2mg/day for 8-16weeks. Fourteen patients were eligible for analysis. Echocardiography was used for assessment of diastolic function. Early diastolic filling velocity (E), late atrial filling velocity (A) and the E/A ratio were included in this study. Peak early diastolic annular velocities (e') were also assessed using color tissue Doppler images. The primary endpoints were changes in the ratio of E to A (E/A), e', and the ratio of E to e' (E/e') from baseline. Pemafibrate significantly increased average e' (7.24 ± 0.58 vs 7.94 ± 0.67, p = 0.019) and a significant reduction in E/e' (9.01 ± 0.94 vs 8.20 ± 0.91, p = 0.041). The increase in e' was significantly related to increases in fasting blood glucose (r = 0.607, p = 0.021) and non-esterified fatty acid (r = 0.592, p = 0.026). Pemafibrate improved diastolic function in patients with T2D and hypertriglyceridemia, suggesting that PPARα activation by pemafibrate prevents the development of DCM at an early stage.

Changes in cardiac time intervals over a decade and the risk of incident heart failure: The Copenhagen City Heart Study

BackgroundThe cardiac time intervals include the isovolumic contraction time (IVCT), the left ventricular ejection time (LVET), the isovolumic relaxation time (IVRT) and the combination of all the cardiac time intervals in the myocardial performance index (MPI) (defined as [(IVCT+IVRT)/LVET)]. Whether the cardiac time intervals change over time and which clinical factors that accelerate these changes is not well-established. Additionally, whether these changes are associated with subsequent heart failure (HF), remains unknown. MethodsWe investigated participants from the general population (n = 1064) who had an echocardiographic examination including color tissue Doppler imaging performed in both the 4th and 5th Copenhagen City Heart Study. The examinations were performed 10.5 years apart. ResultsThe IVCT, LVET, IVRT and MPI increased significantly over time. None of the investigated clinical factors were associated with increase in IVCT. Systolic blood pressure (standardized β= − 0.09) and male sex (standardized β= − 0.08) were associated with an accelerated decrease in LVET. Age (standardized β=0.26), male sex (standardized β=0.06), diastolic blood pressure (standardized β=0.08), and smoking (standardized β=0.08) were associated with an increase in IVRT, while HbA1c (standardized β= − 0.06) was associated with a decrease in IVRT. Increasing IVRT over a decade was associated with an increased risk of subsequent HF in participants aged <65 years (per 10 ms increase: HR 1.33; 95%CI (1.02–1.72), p = 0.034). ConclusionThe cardiac time increased significantly over time. Several clinical factors accelerated these changes. An increase in IVRT was associated with an increased risk of subsequent HF in participants aged <65 years.

Impact of echocardiographic analyses of valvular event timing on myocardial work indices.

Valvular event timing is an integral part of echocardiographic pressure-strain loop (PSL) analyses. The impact that different event timing modalities may have on myocardial work indices is unknown. A methodological study was performed on 200 subjects, including 50 healthy subjects, 50 with aortic valve sclerosis, 50 with atrial fibrillation, and 50 with reduced left ventricular ejection fraction. Valvular event timing was estimated by visual assessment, spectral Doppler, and colour tissue Doppler imaging (TDI) M-mode. These valvular event timings were added to the same PSL analyses sequentially to acquire myocardial work indices, including global work index (GWI). For the 200 participants, the median age was 72 years, 50% were men, and mean blood pressure was 143/80 mmHg. Valvular event timings differed between all three modalities and so did all myocardial work indices. Compared with visual assessment, spectral Doppler resulted in a significantly higher GWI (mean difference: 114 ± 93 mmHg%, P < 0.001), and so did TDI (mean difference: 83 ± 90 mmHg%, P < 0.001). A higher GWI by spectral Doppler than by TDI was also observed (mean difference: 30 ± 53 mmHg%, P < 0.001). In the healthy subgroup, a systematic bias was observed for spectral Doppler compared with visual assessment (mean difference: 160 ± 77 mmHg%, P < 0.001), and a similar trend was noted for TDI vs. visual assessment (mean difference: 124 ± 74 mmHg%, P < 0.001). Myocardial work indices differ depending on the event timing modality used, with visual assessment yielding lower GWI values compared with Doppler-based methods. Serial PSL analyses should apply the same event timing method.

Color tissue doppler imaging of tricuspid annular plane systolic and diastolic excursion in children: A comparison of normal, volume-overloaded and pressure overloaded right ventricles.

Tricuspid annular plane (TAP) systolic excursion (TAPSE) is a reproducible M-mode parameter for the measurement of longitudinal shortening of the right ventricle (RV). To date, all attention has been focused on the systolic excursion of TAP and the diastolic excursion of the annular plane back to the base has been ignored. This study aims to compare the quantitative (excursion, slope, and duration) and qualitative (velocity, acceleration, and indentation) characteristics of TAP systolic and diastolic excursion, using color tissue Doppler imaging, in three groups of children with normal RV (NORV), volume overloaded RV (VORV), and pressure overloaded RV (PORV) and normal pulmonary arterial pressure. A prospective case-control study was performed in three groups of children with normal heart, VORV and PORV. TAPSE and tricuspid annular plane diastolic excursion (TAPDE) were quantitatively and qualitatively analyzed and compared between the three groups. Statistical analysis was performed using IBM SPSS Statistics for Windows. TAPSE, TAPDE, TAPSE slope, TAPSE slope/TAPDE slope, TAPDE duration and TAPDE duration/RR interval were lower in PORV (TAPSE: PORV: 14.45±4.30, NORV: 20.45±5.46, P=.003, TAPDE:PORV: 14.39±4.61, NORV: 20.28±5.65, P=.004, TAPSE slope:PORV: 4.79±1.40, NORV: 7.15±1.98, P=.001, .001, TAPDE duration:PORV: 201.1±87.9 ms, NORV: 292.1±97.9, P=.006, TAPDE duration/RR interval: PORV: .37±.09, NORV: .48±.08, P=.0002). Pressure-overload on RV produced more impairment of TAPSE and TAPDE patterns than volume overload. Values of TAPSE and TAPDE in patients with VORV and PORV stay in two ends of the normal spectrum. The harmful impact of pre-tricuspid volume overload seems to be less than the post-tricuspid volume overload.

Left atrial volumetric/mechanical coupling index in the general population: distribution and prediction of incident atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Copenhagen City Heart Study was funded by the Danish Heart Foundation, and the echocardiographic substudy was further funded by the Lundbeck Foundation. Background Atrial fibrillation (AF) represent a global health burden. Identifying people at risk based on echocardiography has always been challenging. Hence, we aimed to assess the distribution of left atrial volumetric/mechanical coupling index (LACI) in the general population and test its potential to predict incident AF. Methods In a large community-based population study, LACI was calculated by dividing the left atrial (LA) maximal volume by the a’ peak velocity obtained by color Tissue-Doppler Imaging. Clinical endpoint was incident AF. The exclusion criteria were history of AF or previous heart failure. Results A total of 1021 patients formed the study cohort (mean age 52.8 ± 13.3, 45% (n = 459) were male); Median LACI was 2.84 [IQR: 2.14-3.82], rarely exceeding the value of 6. During a follow-up period of 16.1 years (IQR15.6-16.3), 8.9 % (n = 91) of patients developed AF. LACI independently predicted AF (HR 1.11 [1.04-1.17], p = 0.001 unadjusted and HR 1.20 (1.06-1.35), p = 0.003 after a comprehensive multivariable adjustment (including clinical, biochemical, and echocardiographic variables). The Figure illustrates the strong relationship between LACI and the incidence of AF, almost linear, with no plateau effect. In a sensitivity analysis, the association between LACI and incident AF persisted in both hypertensive (HR 1.12 (1.05-1.19) p = 0.001) and non-hypertensive participants (HR 1.18 (1.03-1.35) p = 0.02). Conclusion LACI is a measure of LA function which is routinely available and presents a skewed distribution towards low values in the general population. LACI independently predicts incident AF, irrespective the presence of systemic arterial hypertension. Abstract Figure

Prognostic value of strain rate during isovolumic relaxation in a general population

Abstract Background Left ventricular (LV) strain rate (SR) during isovolumic relaxation (SRIVR) has been shown to correlate with invasive measurements of diastolic function, namely the time constant of LV relaxation (τ), and has thus been proven useful in the assessment of diastolic function. Tissue Doppler imaging (TDI) has an adequate frame rate to resolve the SR during a short-lived mechanical event such as IVR. Purpose The purpose of this study was to assess the additive prognostic value of SRIVR on top of conventional cardiovascular risk factors in a general population. Methods We included 670 subjects (age: 51.2±14.2, 48.8% males) that were already recruited in the Flemish Study on Environment, Genes and Health Outcomes (FLEMENGHO), from May 2005 to February 2009. Subjects were followed up on average 5 years after their recruitment, either by a follow-up visit or by telephone. Exclusion criteria at baseline were atrial fibrillation, presence of an artificial pacemaker, more than mild valvular disease and segmental wall motion abnormalities. All patients underwent echocardiographic examination with a state of the art ultrasound machine. Using an in-house developed software package (SPEQLE), we extracted the velocity, strain and SR curves from the color TDI images (FR &amp;gt;180Hz) and imposed timing information on the IVR based on valve opening/closing as determined from PW Doppler data. The sample volume was positioned at the mid portion of the inferolateral wall, in an apical 3 chamber view, manually tracked over the cardiac cycle and all curves were averaged over 3 subsequent cardiac cycles. Then, SRIVR was estimated as the peak SR value during IVR (Fig. 1). Outcome data consisted of major adverse cardiac events (MACE) during the follow-up period. The hazard ratio (HR) associated with SRIVR values was estimated using Cox regression analysis; we included age, sex, body mass index, systolic blood pressure, smoking and serum cholesterol as co-variables in the model. Results An accurate assessment of the SRIVR in the inferolateral wall was not possible in 34 participants, so further analysis was confined to 636 subjects. In total, 65 adverse cardiac events were recorded over the period of 8.7 years of follow-up. Figure 2 demonstrates the cumulative incidence estimates (1-Kaplan-Meier survival estimates) of composite cardiac events in quartiles of SRIVR measured in the inferolateral wall (log-rank test p=0.005). Overall, after adjustment for the important cardiovascular risk factors, SRIVR of the inferolateral wall analyzed as a continuous variable was a significant predictor of fatal and nonfatal cardiac events (HR 1.94 (95% CI 1.09–3.47); p=0.025). Conclusion SRIVR measured in the inferolateral wall is an important biomarker not only in assessing diastolic function but also as a significant predictor of future adverse outcomes. Funding Acknowledgement Type of funding sources: None.

Assessment of human fetal cardiac autonomic nervous system development using color tissue Doppler imaging.

ObjectivesFunctional development of the fetal cardiac autonomic nervous system (cANS) plays a key role in fetal maturation and can be assessed through fetal heart rate variability (fHRV)‐analysis, with each HRV parameter representing different aspects of cANS activity. Current available techniques, however, are unable to assess the fHRV parameters accurately throughout the whole pregnancy. This study aims to test the feasibility of color tissue Doppler imaging (cTDI) as a new ultrasound technique for HRV analysis. Secondly, we explored time trends of fHRV parameters using this technique.Methods18 healthy singleton fetuses were examined sequentially every 8 weeks from 10 weeks GA onwards. From each examination, 3 cTDI recordings of the four‐chamber view of 10 seconds were retrieved to determine accurate beat‐to‐beat intervals. The fHRV parameters SDNN, RMSSD, SDNN/RMSSD, and pNN10, each representing different functional aspects of the cANS, were measured, and time trends during pregnancy were explored using spline functions within a linear mixed‐effects model.ResultsIn total, 77% (95% Cl 66–87%) of examinations were feasible for fHRV analysis from the first trimester onwards, which is a great improvement compared to other techniques. The technique is able to determine different maturation rates of the fHRV parameters, showing that cANS function, presumably parasympathetic activity, establishes around 20 weeks GA and matures rapidly until 30 weeks GA.ConclusionsThis is the first study able to assess cANS function through fHRV analysis from the first trimester onwards. The use of cTDI to determine beat‐to‐beat intervals seems feasible in just 3 clips of 10 seconds, which holds promise for future clinical use in assessing fetal well‐being.

Kidney function and the prognostic value of myocardial performance index.

A decreased glomerular filtration rate (GFR) is a risk factor for cardiovascular disease even after adjustment for conventional risk factors. The myocardial performance index (MPI) is defined as (isovolumetric relaxation time (IVRT) + isovolumetric contraction time (IVCT))/ejection time (ET). It has been shown to be an independent predictor of cardiovascular events. We hypothesized the MPI could prove valuable for assessing cardiac risk in subjects of the general population with decreased estimated GFR (eGFR). MPI was measured in 1915 subjects from a large general population prospective cohort study using color tissue Doppler imaging (TDI) M-mode through the mitral valve. We compared the prognostic capabilities of the MPI between subjects with eGFR ≥ 75mL/min/1.73m2 and subjects with eGFR < 75mL/min/1.73m2 using multivariable adjusted Cox regression models. The composite endpoint was heart failure, myocardial infarction or cardiovascular death. Mean age was 58years (SD 16.2), 58% were women, 42% had hypertension and 8.3% diabetes. During a median follow-up time of 12.4years [IQR 10.6-12.7years] 269 participants reached the combined endpoint. eGFR modified the prognostic capability of MPI (p-value for interaction < 0.001): After multivariable adjustment, MPI remained an independent predictor of the composite endpoint only in participants with eGFR < 75mL/min/1.73m2: HR 1.18 (95% CI 1.02-1.38), p = 0.03, vs. in subjects with eGFR ≥ 75mL/min/1.73m2: HR 1.14 (95% CI 0.94-1.39), p = 0.17. These results suggest the MPI could be particularly valuable for identifying elevated cardiac risk in individuals from the general population with decreased eGFR.

Evaluation of right heart functions by echocardiography and tissue Doppler imaging echocardiography in obese and non-obese patients with obstructive sleep apnea

Purpose: The aim of our study was to compare the right ventricular systolic and diastolic functions and pulmonary artery pressure (PAP) in obese and non-obese patients with obstructive sleep apnea syndrome (OSAS) by tissue Doppler imaging (TDI) echocardiography.&#x0D; Materials and Methods: This study was conducted with 69 patients, 34 obese and 35 non-obese, diagnosed moderate or severe OSAS by an overnight polysomnographic sleep study. In all patients, LV (left ventricle) and RV (right ventricle) size, left atial (LA) and RA (right atrial) dimensions, LV and RV systolic and diastolic functions and systolic PAPs were measured by M-mode, two-dimensional analysis, color flow Doppler and TDI.&#x0D; Results: RV diastolic dysfunction was detected in both groups; this impairment was significantly higher in the obese group (lateral tricuspid late diastolic myocardial annular zone velocity A'a: 0.13 ± 0.03 in non-obese patients and 0.11 ± 0.04 in obese patients). The mean systolic PAP was significantly higher in obese patients (31.2±5.6, 27.1±5.8, respectively)&#x0D; Conclusion: Obstructive Sleep Apnea Syndrome increases cardiovascular morbidity and mortality. In our study,left ventricul and right ventricul diastolic dysfunction was determined by tissue Doppler imaging in patients with moderate and severe Obstructive Sleep Apnea Syndrome. Obesity contributes to this impairment regardless of Obstructive Sleep Apnea Syndrome .

Cardiac time intervals predict major adverse cardiovascular events in individuals with type 1 diabetes without known heart disease

Abstract Background Cardiac time intervals, and in particular the myocardial performance index (MPI) which combines systolic and diastolic function, are associated with cardiovascular prognosis in various populations. We aimed to investigate if cardiac time intervals offer prognostic information on cardiovascular risk in individuals with type 1 diabetes (T1DM). Methods We prospectively included 1,088 individuals with T1DM without known heart disease (mean age 50±15 years; 53% male; duration of diabetes 26±15 years; 30% had albuminuria). All enrolled individuals underwent an echocardiographic examination with assessment of cardiac time intervals by color Tissue Doppler imaging M-mode. We evaluated the isovolumetric relaxation and contraction time (IVRT; IVCT) and ejection time (ET). The MPI was calculated as [(IVRT+IVCT)/ET]. In Cox proportional hazards models, we assessed major adverse cardiovascular events (MACE), a composite of incident heart failure or hospitalization for acute coronary syndrome or PCI/CABG. Multivariable models were adjusted for clinical information, pharmacotherapy and echocardiographic parameters. Results During the median follow-up time of 6 years [IQR 6, 7 years], 106 (10%) experienced MACE. In adjusted survival analyses the IVRT (HR: 1.13 per 10ms increase [1.01 to 1.26], P=0.026) and MPI (HR: 1.03 per 1 unit increase [1.01 to 1.04], P=0.005) were associated with MACE. Overall, the association between IVCT and outcome was borderline significant (HR: 1.15 per 10ms increase [0.97 to 1.36], P=0.10) while there was no association for ET (HR: 0.97 per 10ms increase [0.89 to 1.05], P=0.43). Sex modified the association for IVCT (P interaction&amp;lt;0.05) such that IVCT (HR: 1.23 per 10ms increase [1.02 to 1.49], P=0.027) and MPI (HR 1.03 per 1 unit increase [1.01 to 1.05], P=0.005; Figure) were associated with MACE in women but not in men. Conclusion Cardiac time intervals are positively associated with MACE in T1D without known heart disease. Furthermore, the association is modified by sex in that the IVCT and MPI provide independent and prognostic information on the risk of future cardiovascular events particularly in female individuals while not significant in men. These findings suggest sex differences in myocardial impairment related to T1D. Association between MACE and MPI in DM1 Funding Acknowledgement Type of funding source: None

Left ventricular systolic ejection time is an independent predictor of all-cause mortality in heart failure with reduced ejection fraction.

Colour tissue Doppler imaging (TDI) M-mode through the mitral leaflet is an easy and precise method to obtain cardiac time intervals including isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT) and systolic ejection time (SET). The myocardial performance index (MPI) is defined as [(IVCT + IVRT)/SET]. Whether cardiac time intervals obtained by the TDI M-mode method can be used to predict outcome in patients with heart failure with reduced ejection fraction (HFrEF) remains unknown. A total of 997 patients with HFrEF (mean age 67 ± 11 years, 74% male) underwent an echocardiographic examination including TDI. During a median follow-up of 3.4 years (interquartile range 1.9-4.8 years), 165 (17%) patients died. The risk of mortality increased by 9% per 10ms decrease in SET [per 10ms decrease: hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.06-1.13; P< 0.001]. The association remained significant even after multivariable adjustment for clinical and echocardiographic parameters (per 10 ms decrease: HR 1.06, 95% CI 1.01-1.11; P=0.030). The MPI was a significant predictor in an unadjusted model (per 0.1 increase: HR 3.06, 95% CI 1.16-8.06; P=0.023). However, the association did not remain significant after multivariable adjustment. No significant associations between IVCT or IVRT and mortality were found in unadjusted nor adjusted models. Additionally, SET provided incremental prognostic information with regard to predicting mortality when added to established clinical predictors of mortality in patients with HFrEF. In patients with HFrEF, SET provides independent and incremental prognostic information regarding all-cause mortality.

Fetal cardiac function at intrauterine transfusion assessed by automated analysis of color tissue Doppler recordings

BackgroundFetal anemia is associated with a hyperdynamic circulation and cardiac remodeling. Rapid intrauterine transfusion (IUT) of blood with high hematocrit and viscosity into the umbilical vein used to treat this condition can temporarily further affect fetal heart function. The aim of this study was to evaluate the short-term changes in fetal myocardial function caused by IUT using automated analysis of cine-loops of the fetal heart obtained by color tissue Doppler imaging (cTDI).MethodsFetal echocardiography was performed before and after IUT. cTDI recordings were obtained in a four-chamber view and regions of interest were placed at the atrioventricular plane in the left ventricular (LV), right ventricular (RV) and septal walls. Myocardial velocities were analyzed by an automated analysis software to obtain peak myocardial velocities during atrial contraction (Am), ventricular ejection (Sm), rapid ventricular filling (Em) and Em/Am ratio was calculated.Myocardial velocities were converted to z-scores using published reference ranges. Delta z-scores (after minus before IUT) were calculated. Correlations were assessed between variables and hemoglobin before IUT.ResultsThirty-two fetuses underwent 70 IUTs. Fourteen were first time transfusions. In the LV and septal walls, all myocardial velocities were significantly increased compared to normal values, whereas in the RV only Sm was increased before IUT (z-scores 0.26–0.52). In first time IUTs, there was a negative correlation between LV Em (rho = − 0.61, p = 0.036) and LV Em/Am (rho = − 0.82, p = 0.001) z-scores and hemoglobin before IUT. The peak myocardial velocities that were increased before IUT decreased, whereas LV Em/Am increased significantly after IUT.ConclusionsThis study showed that peak myocardial velocities assessed by cTDI are increased in fetuses before IUT reflecting the physiology of hyperdynamic circulation. In these fetuses, the fetal heart is able to adapt and efficiently handle the volume load caused by IUT by altering its myocardial function.

Automatic quantification of left ventricular function by medical students using ultrasound

BackgroundAutomatic analyses of echocardiograms may support inexperienced users in quantifying left ventricular (LV) function. We have developed an algorithm for fully automatic measurements of mitral annular plane systolic excursion (MAPSE) and mitral annular systolic (S′) and early diastolic (e′) peak velocities. We aimed to study the influence of user experience of automatic measurements of these indices in echocardiographic recordings acquired by medical students and clinicians.MethodsWe included 75 consecutive patients referred for echocardiography at a university hospital. The patients underwent echocardiography by clinicians (cardiologists, cardiology residents and sonographers), who obtained manual reference measurements of MAPSE by M-mode and of S′ and e′ by colour tissue Doppler imaging (cTDI). Immediately after, each patient was examined by 1 of 39 medical students who were instructed in image acquisition on the day of participation. Each student acquired cTDI recordings from 1 to 4 patients. All cTDI recordings by students and clinicians were analysed for MAPSE, S′ and e′ using a fully automatic algorithm. The automatic measurements were compared to the manual reference measurements.ResultsCorrect tracking of the mitral annulus was feasible in 50 (67%) and 63 (84%) of the students’ and clinicians’ recordings, respectively (p = 0.007). Image quality was highest in the clinicians’ recordings. Mean difference ± standard deviation of the automatic measurements of the students’ recordings compared to the manual reference was − 0.0 ± 2.0 mm for MAPSE, 0.3 ± 1.1 cm/s for S′ and 0.6 ± 1.4 cm/s for e′. The corresponding intraclass correlation coefficients for MAPSE, S′ and e′ were 0.85 (good), 0.89 (good) and 0.92 (excellent), respectively. Automatic measurements from the students’ and clinicians’ recordings were in similar agreement with the reference when mitral annular tracking was correct.ConclusionsIn case of correct tracking of the mitral annulus, the agreement with reference for the automatic measurements was overall good. Low image quality reduced feasibility. Adequate image acquisition is essential for automatic analyses of LV function indices, and thus, appropriate education of the operators is mandatory. Automatic measurements may help inexperienced users of ultrasound, but do not remove the need for dedicated education and training.

LEFT VENTRICULAR SYSTOLIC EJECTION TIME IS AN INDEPENDENT PREDICTOR OF ALL-CAUSE MORTALITY IN HEART FAILURE WITH REDUCED EJECTION FRACTION

Color Tissue Doppler imaging (TDI) M-mode through the mitral leaflet is an easy and precise method to obtain the cardiac time intervals including the isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT) and ejection time (ET) (Figure 1a). Whether the cardiac time intervals can be

Effects of baseline heart rate at sea level on cardiac responses to high-altitude exposure

High-altitude (HA) exposure has been widely considered as a cardiac stress, and associated with altered cardiac function. However, the characteristics of cardiac responses to HA exposure are unclear. In total, 240 healthy men were enrolled and ascended to 4100 m by bus within 7 days. Standard echocardiography and color tissue Doppler imaging were performed at sea level and at 4100 m. In all subjects, HA exposure increased HR [65 (59, 71) vs. 72 (63, 80) beats/min, p < 0.001] but decreased the stroke volume index (SVi) [35.5 (30.5, 42.3) vs. 32.9 (27.4, 39.5) ml/m2, p < 0.001], leading to an unchanged cardiac index (CI). Moreover, baseline HR was negatively correlated with HA exposure-induced changes in HR (r = − 0.410, p < 0.001) and CI (r = − 0.314, p < 0.001). Following HA exposure, subjects with lowest tertile of baseline HR showed an increased HR [56 (53, 58) vs. 65 (58, 73) beats/min, p < 0.001], left ventricular ejection fraction (LVEF) [61.7 (56.5, 68.0) vs. 66.1 (60.7, 71.5) %, p = 0.004] and mitral S′ velocity [5.8 ± 1.4 vs. 6.5 ± 1.9 cm/s, p = 0.040]. However, subjects with highest tertile of baseline HR showed an unchanged HR, LVEF and mitral S′ velocity, but a decreased E′ velocity [9.2 ± 2.0 vs. 8.4 ± 1.8 cm/s, p = 0.003]. Our findings indicate that baseline HR at sea level could determine cardiac responses to HA exposure; these responses were characterized by enhanced LV function in subjects with a low baseline HR and by reduced LV myocardial velocity in early diastole in subjects with a high baseline HR.