Diastolic Pulmonary Vein Research Articles

E/a′ ratio is closely related to pulmonary vein flow profile in patients with normal ejection fraction

Objectives. To compare the ability of the E/a′ ratio and the recommended diastolic parameters in the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI), in predicting a dominant diastolic pulmonary vein flow in patients with normal ejection fraction. Design. We retrospectively evaluated the diastolic function according to the ASE/EACVI guidelines, the S/D ratio and the septal, lateral and average E/a′ ratio in 293 unselected in-hospital patients, aged 39–86 years, in sinus rhythm and with no or mild valve disease, having a normal systolic function (EF > 50%). Results. The S/D ratio had a positive association to septal, lateral and average E/a ratio (R2 = 0.25, 0.35 and 0.32). The association to average E/e′ ratio, LA vol index and TR velocity was weak (R2 = 0.037, 0.033 and 0.087) and for e′ velocity negatively. In patients with S/D ratio <1, septal, lateral, average E/a′ ratio, average E/e ratio, LA vol index (p<.001) and TR velocity (p<.05) were significantly higher compared to patients with S/D ratio ≥1. No significant difference was seen in e′ velocity. The septal, lateral and average E/a′ ratio were significantly higher in patients with S/D ratio <1 regardless a normal or impaired diastolic function according to the ASE/EACVI guidelines (p<.001). The ASE/EACVI algorithm detected 21 patients with S/D ratio <1 compared to 28 patients using average E/a′ ratio with cut-off >14. Conclusion: E/a′ ratio might be a useful new diastolic parameter in patients with a normal ejection fraction as it is more closely related to the S/D ratio than the established ASE/EACVI diastolic parameters.

The a´ velocity in the tissue Doppler predicts S/D ratio

Objectives. To compare the ability of the a´ velocity and the e´ velocity in predicting a dominant diastolic pulmonary vein flow (S/D ratio <1) in patients with normal ejection fraction. Design. We retrospectively evaluated the diastolic function according to the ASE/EACVI guidelines, the S/D ratio and the septal, lateral and average a´ velocity in 293 unselected in-hospital patients, aged 39–86 years, in sinus rhythm and with no or mild valve disease, having a normal systolic function (EF >50%). Results. There was a good linear correlation between the S/D ratio and the a´ velocity, but a tendency towards a negative correlation between the S/D ratio and the e´ velocity. S/D ratio <1 was seen in 43 patients. These patients had a significantly lower a´ velocity compared to those with S/D-ratio ≥1, septal (6,1 ± 2,4 v 8,8 ± 2,1 cm/s; p < .001) and lateral (6,0 ± 2,6 v 9,3 ± 2,5 cm/s; p < .001) No significant difference was seen in the septal e´ velocity (6,8 ± 2,4 v 6,8 ± 2,1 cm/s), lateral e´ velocity (9,4 ± 2,6 v 9,1 ± 2,8 cm/s) or in the ejection fraction (58,6 ± 4,4% v 58,7 ± 4,0%). A diastolic dysfunction was present in 62 patients, normal diastolic function in 231 patients. The a´ velocity was significantly lower in patients with S/D ratio <1 in both groups (p < .01). Conclusion. The a´ velocity is superior to the e´ velocity in predicting S/D ratio <1 in patients with normal ejection fraction regardless the ASE/EACVI diastolic classification. A failing left atrium seems to be the explanation.

Assessment of diastolic dysfunction in patients with acute coronary syndrome and preserved systolic function: comparison between Doppler transthoracic echocardiography and velocity-encoded cardiac magnetic resonance

Objectives Transthoracic echocardiography (TTE) remains the mainstay diagnostic imaging tool for the assessment of diastolic dysfunction. However, velocity-encoded phase-contrast imaging permits evaluation with cardiac magnetic resonance (CMR) with excellent capabilities to assess blood flow and myocardial tissue motion. We evaluated the feasibility of measuring mitral blood flow, mitral annular velocity and pulmonary vein flow in assessing diastolic dysfunction in acute coronary syndrome (ACS) patients.Methods Revascularized acute myocardial infarction patients with normal left ventricular (LV) systolic function on TTE were assessed by 1.5T CMR. Following acquisition of regular short-axis cine volumetry and 2-, 3- and 4-chamber views, we performed single-slice velocity-encoded phase-contrast imaging in short-axis plane at the level of the mitral leaflet tips and in a plane perpendicular to a pulmonary vein. Early, late diastolic mitral inflow velocities, peak systolic, diastolic pulmonary vein velocities and myocardial annular velocities were determined. These were then compared to comparable TTE parameters.Results Fourty-six patients were analyzed. Mean LVEF was 61.1 ± 8.9%. Peak E and A velocities underestimated by CMR, E/A ratio showed a significant correlation with TTE, R2 0.51. Peak S and D velocities also underestimated, S/D ratio significantly correlated with TTE, R2 0.58. Paradoxically, E’ is overestimated by CMR, with lower E/E’ ratio but still significantly correlated with TTE, R2 0.55. Bland-Altman analysis demonstrated excellent agreement with excellent reproducibility.Conclusion CMR evaluation of diastolic dysfunction post-ACS has significant correlation with TTE. Although velocity-encoded phase-contrast imaging underestimates inflow velocities, and overestimates the mitral annular velocity, velocity ratios are consistently correlated with Doppler echocardiography

Effects of Left Ventricular Wall Motion Abnormality on Global and Regional Diastolic Function of the Left and Right Ventricles at Rest and After Stress.

BackgroundDiastolic dysfunction precedes systolic dysfunction in patients with coronary artery disease. The aim of the study was to evaluate the effects of left ventricular (LV) wall motion abnormality (WMA) on diastolic LV and right ventricular (RV) function at rest and after stress.MethodsFifty-nine subjects, 15 with LV-WMA (abnormal group) and 44 without (normal group), underwent dobutamine stress echocardiography (DSE) studies, in addition to evaluation of LV and RV diastolic function before and after DSE.ResultsResting mitral flow parameters were similar. DSE increased peak A-wave velocities in both groups, and mitral color slope only in normal subjects. After DSE, E-wave peak velocities and mitral color slope were higher in normal subjects, P < 0.05. At rest and after DSE systolic and diastolic pulmonary vein velocities were similar in both groups; however, DSE increased these velocities only in normal subjects, P < 0.05. Regional E-wave peak velocities of LV were higher at rest in normal subjects, P < 0.05. Both LV and RV, regional peak E-wave velocities were not affected by DSE. After DSE, regional A-wave peak velocities increased in all (P < 0.01), except at the lateral region (P = 0.07). DSE increased trans-tricuspid velocities in both groups, P < 0.05. Resting A-wave velocities were higher in normal subjects, P < 0.01.ConclusionsGlobal LV early diastolic filling parameters were not affected by LV-WMA at rest. LV-WMA blunted the response after stress. RV E-wave velocities increased after DSE, and were not affected by LV-WMA. LV-WMA reduced regional LV-E’ velocities at rest but not the reserve. A-wave velocities were not affected by WMA and increased after DSE.

Efficacy of Pulmonary Vein Isolation on Left Atrial Function in Paroxysmal and Persistent Atrial Fibrillation and the Dependency on Its Baseline Function

The effects of pulmonary vein (PV) isolation in atrial fibrillation (AF) on left atrial (LA) function or PV flow have not been well documented. We examined the LA function and PV flow before and 3-6 months after PV isolation in 67 AF patients (34 paroxysmal [PAF] and 33 persistent [CAF]) using transesophageal echocardiography. AF recurred in 6/34 patients with PAF and in 6/33 patients with CAF 6 months after PV isolation. A larger LA dimension, a lower systolic PV flow velocity, and a lower ratio of systolic to diastolic PV flow velocity were related to a higher incidence of AF recurrence. The increment of left atrial appendage (LAA) flow velocity (55% vs. 22%) and systolic PV flow velocity (57% vs. 20%) after PV isolation tended to be greater in CAF than in PAF. The changes in LAA flow velocity had reverse correlations with the baseline values before PV isolation (PAF: r = -0.73, CAF: r = -0.58). The changes in mitral flow velocity during atrial contraction in PAF had reverse correlations with the baseline values before PV isolation (r = -0.84). The changes in systolic and diastolic PV flow velocity of PAF had reverse correlations with the baseline values before PV isolation (r = -0.56, r = -0.66). The baseline LA function may affect AF recurrence as well as the improvement of LA function, and the benefit of successful PV isolation might be greater in CAF than in PAF.

Usefulness of Diastolic Dominant Pulmonary Vein Flow to Predict Hospitalization for Heart Failure and Mortality in Ambulatory Patients With Coronary Heart Disease (from the Heart and Soul Study)

Diastolic dysfunction is usually identified by the combination of characteristic mitral and pulmonary vein flow patterns. However, obtaining a complete set of echocardiographic parameters can be technically difficult and data may conflict. We hypothesized that as a stand-alone variable, (ventricular) diastolic dominant pulmonary vein flow would predict heart failure (HF) hospitalizations and cardiovascular death. Standard transthoracic echocardiograms were obtained in 906 subjects from the Heart and Soul Study, a prospective study of the effects of depression on coronary heart disease. Pulmonary vein flow pattern was determined using the dominant velocity-time integral. Cardiac events were determined by 2 independent adjudicators, and Cox proportional hazards models were used. Systolic dominant pulmonary vein flow was present in 89% of subjects, and diastolic dominant, in the remaining 11%. During an average 4.1 years of follow-up, subjects with diastolic dominant pulmonary vein flow had a 25% rate of HF hospitalization and 9% rate of cardiovascular death. After multivariate adjustment including left ventricular ejection fraction, diastolic pulmonary vein flow was associated with a 3-fold risk of HF hospitalization (p = 0.001) and a 2-fold risk of HF hospitalization or death (p = 0.004). In conclusion, diastolic dominant pulmonary vein flow pattern was a stand-alone predictor of adverse cardiac events, and its presence was associated with significantly higher rates of HF hospitalizations and cardiovascular death.

Left Ventricular Global Performance and Diastolic Function in Indeterminate and Cardiac Forms of Chagas’ Disease

The majority of patients with Chagas' disease remain for 10 to 30 years in the indeterminate form (IF) of this disease. They have no symptoms, serologic positivity, normal electrocardiogram results and heart size, and normal left ventricular global and segmental systolic function on 2-dimensional echocardiography. To investigate whether this group of patients have any impairment of left ventricular global performance (Tei index) and diastolic function, we have studied 43 individuals (age 49 +/- 12 years) including 14 healthy volunteers and 29 patients with Chagas' disease divided as IF (n = 12) and cardiac form (n = 17). Echocardiographic measurements included ejection fraction, Tei index, left atrial volume index, transmitral (peak early transmitral flow velocity, late peak mitral velocity, tissue Doppler, late peak mitral velocity duration) and pulmonary (systolic pulmonary vein velocity, diastolic pulmonary vein velocity, retrograde pulmonary vein velocity, retrograde pulmonary vein velocity duration) flow velocities, and tissue Doppler velocities at lateral mitral annulus (peak early transmitral flow velocity, late peak mitral velocity, systolic pulmonary vein velocity). Although ejection fraction and S' velocity were significantly lower for patients with cardiac form compared with control and IF groups, Tei index was not able to differentiate patients with cardiac conditions from the other groups. Diastolic dysfunction was documented for patients with cardiac form by left atrial volume index, early transmitral peak velocity, early expansion wave by tissue Doppler, late expansion wave by tissue Doppler, and peak early transmitral flow velocity/early expansion wave by tissue Doppler. Patients with the IF of Chagas' disease did not show any abnormality of diastolic function. Thus, when the IF is further characterized on the basis of absence of any echocardiographic marker of regional systolic dysfunction, no impairment of diastolic function can be detected.

Augmentation of Pulmonary Vein Backflow Velocity during Left Atrial Contraction: A Novel Phenomenon Responsible for Progression of Atrial Fibrillation in Hypertensive Patients

Background: Atrial fibrillation (AF) is a common arrhythmia showing disease progression. However, echocardiographic prediction of such progression remains incomplete. This study aimed to identify echocardiographic predictors of AF progression in hypertensive patients. Methods: Hypertensive patients with paroxysmal AF were divided into two groups: patients with AF which became permanent (group A; n = 13) and those with AF which remained paroxysmal (group B; n = 46) during the same follow-up period (8.0 ± 2.4 years). Clinical baselines showed no significant differences except for age. Transthoracic echocardiography was recorded 1–2 weeks after termination of the first-detected paroxysms of AF. Results: Echocardiography showed greater left atrial (LA) dimension (p = 0.023) and late diastolic pulmonary vein (PV) backflow velocity (p < 0.001), and a lower LA fractional shortening (p = 0.008) in group A than in group B. Multilogistic regression analysis demonstrated that augmented PV backflow (p = 0.007) and reduced LA fractional shortening (p = 0.032) were independent predictors of the progression of AF. The receiver-operating characteristic curve demonstrated that PV backflow augmentation is the best predictor of future AF perpetuation. Conclusion: PV backflow leading to cyclic stretching of PV musculature contributes to AF progression.

Pulmonary Vein Imaging: Comparison of 3D Magnetic Resonance Angiography with 2D Cine MRI for Characterizing Anatomy and Size

Pulmonary vein imaging is integral for planning atrial fibrillation ablation procedures. We tested the feasibility of quantifying pulmonary vein ostial diameter using two-dimensional cine cardiac magnetic resonance (2D cine CMR) and three-dimensional magnetic resonance angiography (3D MRA). Nine patients with a history of atrial fibrillation and 20 normal volunteers underwent 2D cine CMR and contrast-enhanced 3D MRA of pulmonary veins on a 1.5 T scanner. Pulmonary vein ostial diameters were measured and pulmonary vein vessel border sharpness was graded qualitatively. Both techniques provided excellent pulmonary vein imaging; however, 3D MRA was faster to perform. The average difference between the systolic and diastolic pulmonary vein diameter was 2.5 mm (23.2%, p < 0.0001) in normal volunteers and 2.2 mm (16.9%, p < 0.0001) in atrial fibrillation patients. The ostial diameter measurements by 3D MRA were significantly larger than on 2D cine CMR. Additionally, the pulmonary vein borders appeared sharper with 2D cine CMR compared to 3D MRA. In conclusion, the 2D images can resolve differences in diameter across the cardiac cycle, while the 3D images provide high quality anatomical depiction but blur borders due to pulsatile motion. We suggest a protocol combining 2D cine CMR and 3D MRA for comprehensive evaluation of pulmonary veins.

Serial Doppler assessment of diastolic function before and after the Fontan operation

Serial Doppler echocardiography was used to evaluate the effects of the Fontan operation (FO) on diastolic ventricular function in 55 patients with univentricular heart. Examinations were performed before operation, before postoperative discharge, and 6 months to 6 years postoperatively. Preoperatively, early diastolic atrioventricular valve (E) flow was reduced and deceleration times prolonged relative to healthy children. All pulmonary vein diastolic flow variables, except diastolic velocity, were increased relative to control subjects. After FO, E/atrial velocity and E/atrial time velocity integral ratios were decreased whereas deceleration and isovolumic relaxation time remained constant. Diastolic pulmonary vein forward flow increased after FO. These data suggest inherently abnormal ventricular relaxation in the univentricular heart and that changes in flow patterns observed postoperatively were subtle and likely a result of reduced ventricular preload after FO. Overall, diastolic function most probably remained stable after FO. This information can be used as a benchmark for further diastolic function assessment in patients with surgically palliated univentricular heart.

Maternal diastolic dysfunction and left ventricular geometry in gestational hypertension.

The objective of this study was to evaluate diastolic parameters and left ventricular geometry in gestational hypertension. Twenty-one consecutive pregnant women with gestational hypertension and 21 normotensive women matched for age and gestational age were enrolled in the third trimester of gestation. Echocardiographic and uterine color Doppler evaluations were performed. Systolic, diastolic, and mean blood pressure, total vascular resistance (TVR), and uterine resistance index were higher in hypertensive women than in control subjects (P<0.01). Left atrial function and cardiac output were significantly lower in gestational hypertension (P<0.01). Patients with gestational hypertension had longer left ventricular isovolumetric relaxation time (IVRT) (P<0.0001); lower velocity-time integral of the A wave (P<0.05) and of the diastolic pulmonary vein flow (P<0.05); and higher velocity-time integral of the reverse pulmonary vein flow (P<0.05). Systolic fraction of the pulmonary vein flow was higher in women with gestational hypertension than in control subjects (P<0.01); the difference in duration of pulmonary vein flow and A wave was closer to 0 in gestational hypertension (P<0.0001). Altered left ventricular geometry was found in 100% of hypertensive patients and in 19.05% of normotensive patients (P<0.001). IVRT, left ventricular end-systolic volume, atrial function, and uterine resistance index were directly related to TVR (P<0.01); deceleration time of the E wave showed a quadratic correlation with TVR (P<0.01). Gestational hypertension is characterized by an altered cardiac geometric pattern of concentric hypertrophy. The altered geometric pattern assessed during gestational hypertension is associated, in our study, with depressed systolic function, high TVR, altered diastolic function, and left atrial dysfunction. Deceleration time of the E wave, IVRT, and left atrial fractional area change, found in concomitance with the highest TVR, may be useful in the evaluation of cardiac function and hemodynamics present in pregnancy-induced hypertension.

Efficacy of Doppler Contrast Enhancement to Evaluate the Pulmonary Vein Flow

Background：Sometimes adequate pulmonary venous flow signal could not be obtained in transthoracic echocardiogram. It has been reported that contrast agent that has transpulmonary passage capability could be used in the enhancement of Doppler signal in the left side of the heart. We evaluated the Levovist ® -enhanced pulmonary vein flow signals obtained by transthoracic echocardiogram and compared with those obtained by transesophageal echocardiogram. Method： ： ： ：Ten patients(male 8, female 10, mean age 46±11 with sinus rhythm who underwent transesophageal echocardiogram were enrolled. Spectral Doppler signal intensity(score；0– 5, systolic time velocity integral(Stvi, diastolic time velocity integral(Dtvi of pulmonary vein flow before and after intravenous injection of the contrast were obtained and compared with those obtained by transesophageal echocardiogram. Results：There was no serious side effect related to Levovist ® . Spectral Doppler signal intensity score of pulmonary vein flow with nonenhanced transthoracic echocardiogram was 2.1/5, and adequate Doppler signal could not be obtained in two patients. After contrast enhancement, Doppler signal intensity score rose up to 4.3/5 and adequate Doppler signal could be obtained in all patients. Time velocity integrals of systolic and diastolic pulmonary vein flow obtained by transthoracic echocardiogram correlated well with those obtained by transesophageal echocardiogram. Conclusion：Contrast enhancement of Doppler signal with the agent that has transpulmonary passage capability(Levovist ® is useful in the evaluation of pulmonary vein flow in patient

Estimation of pulmonary artery pressure from pulmonary vein wedge pressure

Correlations between pulmonary artery and pulmonary vein wedge pressures were investigated in 13 patients with atrial septal defect and 1 patient with Tetralogy of Fallot. Pulmonary vein wedge pressure wave form resembled that of pulmonary artery pressure, and the former lagged behind the latter by 70 to 110 msec (mean 88 +/- 14) as observed by the fluid-filled catheter system. Diastolic pulmonary artery and diastolic pulmonary vein wedge pressures were nearly identical. Although systolic and mean pulmonary artery pressures correlated well with respective pulmonary vein wedge pressures, there were discrepancies when systolic and mean pulmonary artery pressure exceeded 35 and 20 mm Hg, respectively. However, systolic and mean pulmonary artery pressures could be estimated by adding the difference between the diastolic pulmonary vein wedge pressure and the mean left atrial pressure to corresponding systolic or mean pulmonary artery pressure. In conclusion, pulmonary artery pressures can be estimated by measuring pulmonary vein wedge pressures and the mean left atrial pressure.

Influence of pericardial constraint on atrioventricular interactions.

The effects of the pericardial constraint in control, tamponade, and absent pericardium conditions was studied in 18 anesthetized open-chest dogs. Atrial pressures and systolic and diastolic inflow volumes per beat in the superior (SVC), inferior vena cavae (IVC), and pulmonary vein (PV) were measured. With increasing tamponade, 1) the systolic-diastolic distribution of venous flow became almost exclusively systolic in the SVC (P less than 0.001) and IVC (P less than 0.05), as the gamma-descent disappeared; 2) similar but lesser left-sided changes occurred in PV flows (P less than 0.001) and pressure; and 3) the systolic-diastolic distribution of venous flow was modulated by heart rate. The results imply that during tamponade 1) increased pericardial liquid pressure associated with an increased pericardial constraint couples reciprocal atrial and ventricular volume changes; 2) the atria fill during ventricular ejection (atrioventricular interaction); 3) total heart volume must have been relatively constant throughout a cardiac cycle; and 4) differences in right and left heart compliances may explain persistent diastolic PV flow. Pericardiotomy produced a small increase in the ratio of diastolic to systolic venous inflow volumes (P less than 0.025), suggesting that normally the pericardium has a minor influence on atrioventricular interaction, the volume changes in the atria and ventricles being relatively uncoupled. With severe tamponade, a homogeneous pericardial fluid column tightly couples atrial and ventricular volume changes and accounts for the characteristic changes in atrial pressure waveforms and patterns of venous flow.