Pattern Of Diastolic Dysfunction Research Articles

Infiltrative Nonamyloidotic Monoclonal Immunoglobulin Light Chain Cardiomyopathy: An Underappreciated Manifestation of Plasma Cell Dyscrasias

Background: Infiltrative cardiomyopathies are characterized by diastolic dysfunction. In monoclonal plasma cell dyscrasias, organ compromise may be produced by tissue deposition of monoclonal immunoglobulins or their constituent peptides independently of the effects of unbridled plasma cell proliferation. The deposits may be fibrillar, as in light chain amyloid (AL) or nonfibrillar, as in light chain deposition disease (LCDD). AL disease of the heart is a restrictive cardiomyopathy. We hypothesized that, despite differences in physical properties, nonamyloidotic light chain deposition in the myocardium could produce similar clinical and physiological abnormalities. Methods: Cardiac tissue from five patients with LCDD and cardiac dysfunction was examined by immunohistochemical and electron microscopic techniques. Hospital charts, electrocardiograms, echocardiograms and cardiac catheterization results were reviewed. In two cases, the original echocardiograms were reanalyzed. Results: The five patients with nonamyloidotic light chain deposits in the myocardium had either mechanical or electrocardiographic abnormalities. In four with adequate clinical documentation, the diastolic dysfunction and conduction abnormalities were similar or identical to that described in cardiac AL disease. Conclusions: Although nonamyloidotic immunoglobulin light chain deposits in the myocardium differ in distribution and ultrastructural organization from the fibrillar deposits of AL disease, an analogous pattern of diastolic dysfunction and conduction disturbances results. The diagnosis should be considered in patients with a plasmacytic dyscrasia and restrictive cardiomyopathy in whom Congo red staining of endomyocardial biopsy tissue is negative. The diagnosis can be established by using the appropriate immunohistochemical and ultrastructural tissue examinations.

Recovery of Left Ventricular Diastolic Function after Coronary Bypass Surgery

Effects of myocardial revascularization in patients with preoperative left ventricular diastolic dysfunction have not been well characterized. The aim of this study was to evaluate the recovery of diastolic function following successful coronary artery bypass surgery. Forty-five patients with normal diastolic function were selected for comparison with 45 patients who had a pattern of diastolic dysfunction. Mitral flow peak velocity ratios and atrial filling fractions were measured by pulsed Doppler echocardiography 24 hours before surgery. Diastolic dysfunction was defined as a mitral flow peak velocity ratio of less than one. After coronary artery bypass graft surgery, patients who required hemodynamic support were excluded from further study. Group 1 consisted of 38 patients (mean age, 59 ± 9 years) with normal preoperative peak velocity ratios. Group 2 consisted of 33 patients (mean age, 52 ± 9) with preoperative diastolic dysfunction. In group 1, mitral flow peak velocity ratios decreased immediately after cardiopulmonary bypass and persisted for 24 hours, returning to normal at 72 hours. In group 2, peak velocity ratios decreased immediately after cardiopulmonary bypass and persisted for 10 days. Similar changes occurred in atrial filling fractions in the 2 groups. These findings indicate that recovery of left ventricular diastolic function is prolonged in patients with preoperative dysfunction, which may reflect the time required for reversal of the effects of chronic myocardial ischemia.

Diastolic function in children and adolescents on dialysis and after kidney transplantation: an echocardiographic assessment.

Thirty-seven children and adolescents on renal replacement therapy (11 on haemodialysis, 14 on continuous ambulatory peritoneal dialysis and 12 after renal transplantation) were studied by echocardiography, echo-Doppler and phonocardiography. Right and left ventricular (R/L V) diastolic functions were measured by transmitral and transtricuspid flow velocities and by LV isovolumic relaxation time (LVIRT). Thirty-seven age- and sex-matched healthy subjects served as controls. R/L V diastolic dysfunction was only observed in the dialysis patients. In these patients LVIRT was prolonged. LV and RV peak inflow velocities were increased both in early (E) and late (A) diastole with a reduction in the E/A ratios. This pattern of diastolic dysfunction is compatible with the combined effects of a hypercirculatory state (volume overload, anaemia, arteriovenous fistula) and an abnormality of cardiac relaxation. The transplant patients showed no major cardiac abnormalities.

Left ventricular filling is usually normal in uncomplicated coronary disease

Abnormalities in left ventricular filling have been described as an early finding in coronary artery disease (CAD) and more recently, in hypertension (HTN). The present study was undertaken to compare the prevalence and pattern of diastolic dysfunction in these two entities. Three groups of patients were studied: 10 normal volunteers (NLS), 39 HTN patients, and 30 CAD patients. The CAD patients were divided into two subgroups—one with normal ejection fraction (mean 0.60 ± 0.06) and the second with either a depressed ejection fraction (EF) or a history of HTN (mean EF 0.44 ± 0.15). The diastolic indices examined were peak filling rate (PFR, in end-diastolic volume [EDV]/sec), time to peak filling rate (TPFR, in msec), and first-third filling fraction ( FF1 3 , in sec −1). The PFR in CAD and HTN was significantly reduced (1.86 ± 0.63 and 2.29 ± 0.49 vs 2.70 ± 0.35 EDV/sec in NLS, p < 0.025 and p < 0.001, respectively), with the CAD group also being significantly lower than the HTN group ( p < 0.005). TPFR was prolonged in HTN, but not in CAD. FF1 3 was reduced in both HTN and CAD (0.38 ± 0.11 and 0.50 ± 0.14 vs 0.61 ± 0.06 sec −1 in NLS, p < 0.001 and p < 0.025, respectively), but it was significantly lower in HTN than in CAD ( p < 0.001). However, when the subgroup of CAD patients with normal global systolic function was examined separately, diastolic indices were only slightly depressed. More importantly, only one, two, and five patients had PFR, TPFR, and FF1 3 , respectively, which were below the normal values of our laboratory.