Diastolic Duration Ratio Research Articles

EP09.06: Doppler evaluation of systolic to diastolic duration ratio in normal fetuses from 18 to 41 weeks of gestation

EP09.06: Doppler evaluation of systolic to diastolic duration ratio in normal fetuses from 18 to 41 weeks of gestation

Comparison of echocardiographic measurements to invasive measurements of diastolic function in infants with single ventricle physiology: a report from the Pediatric Heart Network Infant Single Ventricle Trial.

While echocardiographic parameters are used to quantify ventricular function in infants with single ventricle physiology, there are few data comparing these to invasive measurements. This study correlates echocardiographic measures of diastolic function with ventricular end-diastolic pressure in infants with single ventricle physiology prior to superior cavopulmonary anastomosis. Data from 173 patients enrolled in the Pediatric Heart Network Infant Single Ventricle enalapril trial were analysed. Those with mixed ventricular types (n = 17) and one outlier (end-diastolic pressure = 32 mmHg) were excluded from the analysis, leaving a total sample size of 155 patients. Echocardiographic measurements were correlated to end-diastolic pressure using Spearman's test. Median age at echocardiogram was 4.6 (range 2.5-7.4) months. Median ventricular end-diastolic pressure was 7 (range 3-19) mmHg. Median time difference between the echocardiogram and catheterisation was 0 days (range -35 to 59 days). Examining the entire cohort of 155 patients, no echocardiographic diastolic function variable correlated with ventricular end-diastolic pressure. When the analysis was limited to the 86 patients who had similar sedation for both studies, the systolic:diastolic duration ratio had a significant but weak negative correlation with end-diastolic pressure (r = -0.3, p = 0.004). The remaining echocardiographic variables did not correlate with ventricular end-diastolic pressure. In this cohort of infants with single ventricle physiology prior to superior cavopulmonary anastomosis, most conventional echocardiographic measures of diastolic function did not correlate with ventricular end-diastolic pressure at cardiac catheterisation. These limitations should be factored into the interpretation of quantitative echo data in this patient population.

Determination of right ventricular function with adjusted systolic to diastolic duration ratio after transannular patch repair of tetralogy of Fallot.

Early detection of right ventricular dysfunction after transannular patch for tetralogy of Fallot (TOF-TAP) is essential for management. To evaluate echocardiographic metrics of ventricular function correlate with functional MRI measurements, in patients with TOF-TAP. A retrospective review of patients with TOF-TAP between 2007 and 2017 who had an echocardiogram and MRI within six months were analyzed. Systolic to diastolic ratio (SD ratio) was measured from the tricuspid regurgitation and adjusted for heart rate. Tricuspid Annular Plane Systolic Excursion (TAPSE), Fractional Area Change (FAC), and shortening fraction (SF) were additionally measured. Echocardiographic measurements were correlated with MRI assessment of right ventricular ejection fraction (RVEF), left ventricular ejection fraction (LVEF), right ventricular end-diastolic volume index (RVEDi), and right to left ventricle volume ratio (RV/LV). Of the 53 patients (mean age 12.8years) that met inclusion criteria, 45 (85%) had available TR jets for SD ratio analysis. The HR adjusted SD ratio negatively correlated with RVEF (r=-.359, P=.016), LVEF (r=-.317, P=.038) and positively with RV/LV EDV ratio (r=.347, P=.024). TAPSE, FAC, and SF measurements did not show significant correlation. In patients with TOF-TAP, there is a moderate negative correlation between heart rate adjusted SD ratio and MRI metrics of ventricular function, suggesting that decreased filling time is a marker for reduced right ventricular function. The SD ratio may be a useful echocardiographic tool for serial evaluation of in this population.

Prevalence and risk factors for low bone density in adults with a Fontan circulation.

This study aimed to characterize bone mineral density abnormalities and pathophysiological associations in young adults living with a Fontan circulation. Participants underwent bone mineral density measurement using dual-energy X-ray absorptiometry and serum biochemical analysis, cardiopulmonary exercise and strength testing and transthoracic echocardiography. In our cohort (n=28), 29% had osteopenic-range bone mineral density and one patient was osteoporotic (average hip t score: -0.6±1.1; spine t score: -0.6±0.9). Four patients (14%) had z scores<-2.0. Parathyroid hormone levels were increased compared with laboratory median (6.1±3.5 vs 4pmol/L, P=.01) and 27% had 25-hydroxy-vitamin D<50nmol/L. 25-hydroxy-vitamin D negatively correlated with parathyroid hormone (ρ=-0.53, P=.01) suggesting secondary hyperparathyroidism. Atrioventricular valve systolic to diastolic duration ratio, an echocardiographic measure of diastolic dysfunction, inversely correlated with hip t and z scores (P<.01). Hip t scores were positively associated with oxygen saturations (ρ=0.45, P=.05) and tended to be inversely associated with parathyroid hormone levels (ρ=-0.44, P=.07) and N-Terminal pro b-type natriuretic peptide (ρ=-0.42, P=.08). Many young adults with a Fontan circulation have abnormal bone mineral density. The underlying pathophysiology is likely multifactorial. Possible contributors include secondary hyperparathyroidism, hypoxemia, diastolic cardiac dysfunction and neurohormonal activation. As low bone mineral density is clinically relevant and potentially treatable, assessment of bone mineral density should be part of routine care in this cohort.

Right ventricular systolic to diastolic duration ratio: A novel predictor of outcome in adult idiopathic pulmonary arterial hypertension

BackgroundThe systolic to diastolic (SD) duration ratio reflects global RV performance in pulmonary arterial hypertension (PAH) yet limited data exists on its application to adult non-congenital PAH. We measured SD ratios on echocardiogram in idiopathic PAH (IPAH) to establish its response to pulmonary vasodilator therapy and prognostic value at diagnosis and follow up. MethodsIncident patients with IPAH undergoing echocardiogram, haemodynamic and exercise assessments were identified within our centre between 2005 and 2018. SD ratios were adjusted for heart rate at diagnosis and follow up. ResultsIn 98 patients at diagnosis, the mean SD ratio was 1.03 ± 0.37 decreasing to 0.85 ± 0.25, p < 0.001 at follow-up echocardiogram performed at a median interval of 9.0 months. The SD ratio at diagnosis correlated weakly with RV basal diameter (r = 0.24, p = 0.04) and 6MWD (r = 0.23, p = 0.04). At follow up, the mean SD ratio was lower in those receiving combination vs monotherapy pulmonary vasodilator treatment (71 ± 25 vs 92 ± 22% baseline respectively, p < 0.001). After a median follow-up of 4.8 years, 3 patients were transplanted and 23 patients died. The SD ratio at diagnosis and follow up predicted an increased risk of death/transplantation (HR 2.41 (1.09–5.29), p = 0.03; HR 5.02 (1.27–19.77), p = 0.02 respectively), retaining its predictive value at diagnosis in bivariate models with 6MWD (HR 2.18 (1.06–4.08)), WHO Functional Class (HR 2.33 (1.04–5.21)) and TAPSE (HR 2.36 (1.07–5.19)), all p < 0.05. ConclusionsThe SD ratio carries prognostic value at diagnosis and follow up in IPAH. Its further evaluation alongside current PAH risk stratification parameters should be considered.

P4537Prolonged right ventricular systolic to diastolic duration ratio predicts mortality in idiopathic pulmonary arterial hypertension

P4537Prolonged right ventricular systolic to diastolic duration ratio predicts mortality in idiopathic pulmonary arterial hypertension

Prognostic Value of a Simple Echocardiographic Parameter, the Right Ventricular Systolic to Diastolic Duration Ratio, in Patients with Advanced Heart Failure with Non-Ischemic Dilated Cardiomyopathy.

The prognostic value of the right ventricular (RV) systolic to diastolic duration ratio (S/D ratio) in patients with advanced heart failure is not clear.We enrolled 45 patients with DCM (40 ± 13 years, 33 male) who were admitted to our hospital for evaluation or treatment of heart failure. The RV systolic and diastolic durations were measured using continuous Doppler imaging of tricuspid regurgitation, and the RV S/D ratio was calculated. Cardiac events were defined as cardiac death or left ventricular assist device implantation within the first year. Twenty-eight cardiac events occurred. The RV S/D ratio was significantly higher in the event group than in the event-free group (1.8 ± 0.8 versus 1.2 ± 0.5, P = 0.008). Univariate analysis showed that the RV S/D ratio, plasma brain natriuretic peptide concentration, left atrial volume index, and mitral deceleration time were associated with these events. Receiver operating characteristic curve analysis revealed that the optimal RV S/D cutoff value to predict events was 1.2 (sensitivity 79%, specificity 65%, area under the curve 0.745). Kaplan-Meier analysis indicated a significantly higher event rate in patients with an RV S/D ratio > 1.2 (log-rank test, P = 0.003). The addition of an RV S/D ratio > 1.2 improved the prognostic utility of a model that included conventional variables (P = 0.014).In patients with advanced heart failure with DCM, the RV S/D ratio was higher in patients with events than in those without events. The addition of the RV S/D ratio to conventional parameters may provide better prognostic information.

Evaluation of the relationship between ventricular end-diastolic pressure and echocardiographic measures of diastolic function in adults with a Fontan circulation

BackgroundEchocardiographic assessment of diastolic function in the setting of Fontan physiology is not well validated. We recently demonstrated that atrioventricular systolic to diastolic duration ratio (AVV S/D ratio) independently predicts mortality in Fontan-adults and that a value >1.1 was associated with poor prognosis. PurposeTo correlate echocardiographic measures of diastolic function with direct measurement of ventricular end-diastolic pressure (VEDP). MethodsA retrospective analysis was undertaken of Fontan-adults who had transthoracic echocardiography (TTE) within 12 months of direct measurement of VEDP during cardiac catheterisation. ResultsFifteen Fontan adults (3 males, mean age 29 ± 9 years) were evaluated. Thirteen patients had dominant morphologic left ventricle and 2 had morphologic right ventricle. Four had atriopulmonary connection and 11 had total cavopulmonary connection. Twelve patients were NYHA Class I/II and 3 were Class III. Time between TTE and cardiac catheter was 46 ± 113 days; VEDP was 8 ± 5 mmHg. Ten patients had preserved ventricular function, 3 had mild and 2 had moderate systolic impairment by subjective TTE assessment. AVV S/D ratio had the strongest correlation with VEDP (r = 0.8, p = 0.001). AVV S/D ratio ≥ 1.1 had 100% positive predictive value and 92% negative predictive value for detecting VEDP >10 mmHg. The only conventional echocardiographic measure of diastolic function that correlated with VEDP was pulmonary vein A wave - atrioventricular A wave duration difference (r = 0.8, p = 0.02). ConclusionsTTE measures reflect VEDP in adults with a Fontan circulation. AVV S/D ratio is a simple parameter yet to enter standard practice that can be used to identify elevated VEDP.

Biventricular function on early echocardiograms in neonatal hypoxic-ischaemic encephalopathy.

To compare early (<24 hours) echocardiograms (ECHOs) in infants with perinatal hypoxic-ischaemic encephalopathy (HIE) undergoing (i) therapeutic hypothermia (TH), (ii) normothermia and (iii) normal controls. This was a single-centre retrospective review of clinical early ECHOs of term infants with moderate or severe HIE and controls (with a normal ECHO <72 hours of age). Right (RVO) and left ventricular output (LVO), RV and LV myocardial performance index (MPI), systolic to diastolic duration ratio (S/D) and eccentricity indices (EI) in systole and diastole were compared using ANOVA. Among infants with HIE (n = 56, 38 in the TH and 18 in normothermia groups), 14 (25%) infants died and 42 survived. Significantly elevated biventricular MPI, lower RVO and LVO and pulmonary hypertension (abnormal EI, higher RV S/D and bidirectional or right-to-left ductal shunt) were found in groups with HIE, compared to controls (n = 35). LV MPI was lower in HIE-TH, compared to the HIE-normothermia group. Infants with HIE who died (n = 14) had a significantly lower EId [0.77 (0.09) vs. 0.83 (0.08), p = 0.021] compared to survivors (n = 42). Infants with perinatal HIE have ventricular dysfunction; those who died had significantly lower EId than survivors; this association needs to be further validated.

Abstract 10259: Echocardiographic Predictors of Mortality in Adults With a Fontan Circulation

Introduction: Transthoracic echocardiographic (TTE) parameters that predict mortality have not been well-defined in Fontan-adults. Atrioventricular valve systolic to diastolic duration ratio (AVV S:D) is an echocardiographic indice that reflects global cardiac performance but has not been studied in this setting. AVV S:D may be useful in this heterogeneous group as it does not rely on geographic assumption or segmental analysis. Methods: Fontan-adults (≥18 years) in sinus or A-paced V-sensed rhythm seen at our institution since 2005 were studied prospectively. Clinical data were recorded from time of index TTE. Subjects were censored at death or most recent review. Nil had cardiac transplant. Results: In total, 128 patients (64 male) were included, mean age was 27 ± 8 years, 107 had dominant left ventricle (LV), 18 had dominant right ventricle (RV) and 3 were biventricular with large ventricular septal defect. Forty-eight had atriopulmonary connection (APC), 64 had total cavopulmonary connection (TCPC) and 16 had TCPC conversion. Time since first repair was 22 ± 7 years. Mean NYHA Class was 1.4 ± 0.6. During mean follow-up of 4.3 ± 2.8 years, 12 patients died (1 dominant RV, 11 dominant LV). Eight deaths were due to heart failure, 2 were sudden death and 2 were due to liver failure. In univariate analysis the strongest TTE predictors of mortality were AVV S:D, presence of restrictive filling using pulse and tissue Doppler parameters, subjective grade of systolic ventricular function, fractional area change and moderate to severe AVV regurgitation. Results with p ≤ 0.2 are shown in Figure 1. Cox regression analysis suggested NYHA Class and AVV S:D were independent predictors of mortality (p&lt;0.0001 for both). Conclusions: TTE indices are predictive of mortality in Fontan-adults. Ventricular performance assessed by AVV S:D was the most important parameter and should be incorporated into routine clinical assessment of these patients.

Prognostic implications of the systolic to diastolic duration ratio in children with idiopathic or familial dilated cardiomyopathy.

Childhood dilated cardiomyopathy (DCM) carries high morbidity and mortality. The echocardiographic systolic to diastolic (S:D) duration ratio, an indicator of global cardiac performance, is elevated in DCM; however, its prognostic implications have not been investigated in this population. We investigated systolic and diastolic durations and the resultant S:D ratio using pulsed tissue Doppler imaging in children with idiopathic or familial DCM. We studied serial echocardiograms from presentation until the last follow-up echo. Results were compared with heart rate-matched controls and between DCM subgroups based on an acute or insidious presentation. The association between S:D ratio and death or need for transplant was analyzed. All analyses were adjusted for repeated measures per patient. We studied 200 serial echocardiograms of 48 children with DCM (7.0±6.0 years) and 25 controls. Adjusted for repeated measures through a compound symmetry covariance structure, the S:D ratio was higher in DCM patients (-0.425 [0.072]; P<0.001) because of shortened diastole. A S:D ratio >1.2 at presentation and on serial evaluation was associated with a hazard ratio of 10.5 (95% confidence interval, 3.9-27.8; P<0.001) for death or transplant. In combined multivariable analysis, a S:D ratio >1.2 remained significantly associated with hazard of death/transplant (hazard ratio, 9.1; P=0.04) after adjustment for ejection fraction (hazard ratio: 2.2 per -10%; P<0.001). A high S:D ratio is associated with increased risk for death or need for transplant in children with DCM across the spectrum of heart rates and may be a useful prognostic index for serial evaluation of children with DCM.

Right Ventricular Diastolic Performance in Children With Pulmonary Arterial Hypertension Associated With Congenital Heart Disease

Background— Right ventricular diastolic dysfunction influences outcomes in pulmonary arterial hypertension (PAH), but echocardiographic parameters have not been investigated in relation to invasive reference standards in pediatric PAH. We investigated echocardiographic parameters of right ventricular diastolic function in children with PAH in relation to simultaneously measured invasive reference measures. Methods and Results— We prospectively recruited children undergoing a clinically indicated cardiac catheterization for evaluation of PAH and pulmonary vasoreactivity testing. Echocardiography was performed simultaneously with invasive reference measurements by high-fidelity micromanometer catheter. For analysis, patients were divided into shunt and nonshunt groups. Sixteen children were studied. In the group as a whole, significant correlations were found among τ and tricuspid deceleration time, E′ , E/E′ , Time E – E ′ , A wave velocity, and global early and late diastolic strain rate. d p /d t minimum correlated significantly with late diastolic tricuspid annular velocity ( A′ ), tissue Doppler imaging–derived systolic:diastolic duration ratio, and global late diastolic strain rate. End-diastolic pressure correlated significantly with tissue Doppler imaging–derived systolic:diastolic duration ratio. On multivariate analysis, tricuspid deceleration time, Time E – E ′ , and global early diastolic strain rate were independent predictors of τ, whereas tissue Doppler imaging–derived systolic:diastolic duration ratio was an independent predictor of d p /d t minimum. In general, correlations between echocardiographic and invasive parameters were better in the shunt group than in the nonshunt group. Conclusions— Echocardiography correlates with invasive reference measures of right ventricular diastolic function in children with PAH, although it does not differentiate between early versus late diastolic abnormalities. Newer echocardiographic techniques may have added value to assess right ventricular diastolic dysfunction in this population.

Global myocardial function is compromised in infants with pulmonary hypertension

Persistent pulmonary hypertension of the newborn is a serious clinical entity with significant mortality and long-term morbidity. The objective was to study the profile of myocardial function, especially diastolic function, in term infants with pulmonary hypertension treated with nitric oxide. Unit electronic database was accessed to identify infants ≥34 weeks gestation who were administered nitric oxide for pulmonary hypertension over the last 6 years. Medical records and archived echocardiographic images were retrieved. Those with no echocardiogram on the day of administration of nitric oxide, concomitant congenital heart disease or ≥2 weeks of age at the time of nitric administration were excluded. Low biventricular outputs were noted in >2/3rd infants. Tricuspid regurgitation was noted in 20/25 (80%) infants, and ductal shunt was bidirectional in the majority of cases. Right ventricular diastolic function was assessed by systolic to diastolic duration ratio; dysfunction was widely prevalent. A large percentage of infants were haemodynamically severely compromised. This is the first study to detail right ventricular diastolic dysfunction in infants with pulmonary hypertension and highlights the therapeutic role of milrinone, a lusitropic drug with myocardial relaxation properties. Comprehensive evaluation of cardiovascular haemodynamics can optimize clinical care.

Usefulness of the Right Ventricular Systolic to Diastolic Duration Ratio to Predict Functional Capacity and Survival in Children With Pulmonary Arterial Hypertension

The objective of this study was to investigate the systolic to diastolic duration ratio (S:D ratio) in children with pulmonary arterial hypertension (PAH) and its association with right ventricular (RV) performance, hemodynamics, 6-minute walk test, clinical outcomes, and survival. We reviewed 503 serial echocardiograms in 47 children with PAH (mean pulmonary artery pressure >or=25 mm Hg) and compared the S:D ratio, assessed from Doppler flow of tricuspid valve regurgitation, to that in 47 age-matched controls. We reviewed echocardiograms, catheterization data, 6-minute walk tests, clinical data, lung transplantation, and death and used univariate linear regression models with a maximum likelihood algorithm for parameter estimation to investigate associations between S:D ratio and RV function, hemodynamics, functional capacity, and clinical outcomes. The S:D ratio was significantly higher in patients than in controls (1.38 +/- 0.61 vs 0.72 +/- 0.16, p <0.001). A higher S:D ratio was associated with worse echocardiographic RV fractional area of change, worse catheterization hemodynamics, shorter 6-minute walk distance, and worse clinical outcomes independent of pulmonary resistance or pressures. An increase of 0.1 in the S:D ratio was associated with a 13% increase in yearly risk for lung transplantation or death (hazard ratio 1.13, p <0.001). An S:D ratio 1.00 to 1.40 was associated with a moderate risk and an S:D ratio >1.40 was associated with a high risk of a negative outcome. In conclusion, in children with PAH, an increased S:D ratio is temporally associated with worse RV function, hemodynamics, exercise capability, clinical status, and survival.

The Systolic to Diastolic Duration Ratio in Children with Hypoplastic Left Heart Syndrome: A Novel Doppler Index of Right Ventricular Function

Right ventricular (RV) function is an important determinant of clinical status in children with hypoplastic left heart syndrome (HLHS). However, assessment of RV function remains challenging because of its complex morphology. We investigated the S/D duration ratio in children with HLHS as a novel index of global RV function. We measured systolic (S) and diastolic (D) duration using tricuspid regurgitation duration from Doppler flow, to calculate the S/D ratio in 33 children with HLHS and 33 control subjects matched for age and sex. We compared the S/D ratio between patients with HLHS and control subjects, between patients with HLHS and normal and abnormal RV function, and between patients with HLHS at different stages of palliation. We further correlated the S/D ratio with catheterization data. Patients and control subjects were well matched for age (3.12 +/- 4.5 vs 3 +/- 4.5 years, not significant) sex, and heart rate (cycle length 524 +/- 179 vs 575 +/- 162 milliseconds, not significant). Patients with HLHS had a significantly higher S/D ratio than control subjects (1.65 +/- 0.85 vs 0.85 +/- 0.2, P < .0001). The S/D ratio became increasingly elevated in HLHS at higher heart rates, but not in control subjects. The S/D ratio was significantly higher in patients with HLHS and decreased RV function as compared with patients with HLHS and normal RV function (2.2 +/- 0.7 vs 1.5 +/- 0.47, P = .006), and significantly increased in patients with Norwood stage 1 versus patients with Norwood stages 2 and 3 HLHS (2.16 vs 1.4 and 1.32, respectively, P < .01 and P < .001, respectively). The S/D ratio did not correlate with catheterization-derived RV end-D pressure or cardiac index. Patients with HLHS have an increased S/D ratio as a result of a shortened D and prolonged S. Measurement of the S/D duration ratio using Doppler flow is a novel method to augment assessment of global RV function in HLHS.

The Systolic to Diastolic Duration Ratio in Children with Heart Failure Secondary to Restrictive Cardiomyopathy

Systole (S) and diastole (D) are fundamental to cardiac function, yet their durations are not routinely evaluated. We defined the S/D duration ratio in 11 children with restrictive cardiomyopathy (CM) and 31 control subjects, using tricuspid regurgitant flow duration. We correlated S/D ratio, S duration, and D duration with heart rate and compared groups. Heart rates of control subjects and patients with restrictive CM were similar (P = .995). The S/D ratio was higher in patients with restrictive CM than in control subjects (1.6 +/- 0.81 vs 0.8 +/- 0.19, P < .001) as a result of shortened D (0.43 +/- 0.13 vs 0.56 +/- 0.06, P < .01) and prolonged S (0.58 +/- 0.12 vs 0.44 +/- 0.06, P < .01). The S/D ratio was highly correlated to heart rate in restrictive CM (r = 0.95, P < .0001). The high S/D ratio found in restrictive CM, found also in dilated CM, suggests that this index is generic to heart failure rather than to a specific disease. The S/D ratio is easily measured using Doppler flow, enhancing echocardiographic assessment of D function in children.