Early Diastolic Mitral Inflow Velocity Research Articles

Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques

ObjectiveThe objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%. MethodsSeventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)—SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis. ResultsIn comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e'), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A. ConclusionsPatients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

Prognostic value of E/e’ ratio and its change over time in ST-segment elevation myocardial infarction with preserved left ventricular ejection fraction in the reperfusion era

BackgroundThe ratio of early diastolic mitral inflow velocity to mitral annular velocity (E/e’) is a prognostic factor in patients with ST-segment elevation myocardial infarction (STEMI). However, data are lacking on long-term outcomes and longitudinal changes in E/e’ in patients with preserved left ventricular ejection fraction (LVEF) in the reperfusion era. MethodsThis is a pre-specified echocardiographic substudy of a randomized controlled trial evaluating the efficacy of beta-blockers in STEMI patients with LVEF ≥40 % after primary percutaneous coronary intervention (PCI). Patients were divided into 2 groups according to E/e’ at discharge: ≤14 (normal E/e’ group) or > 14 (high E/e’ group). The primary outcome was a composite of all-cause death, myocardial infarction, stroke, acute coronary syndrome, and heart failure hospitalization. We also assessed longitudinal changes in E/e’ and conducted a landmark analysis using E/e’ at 1 year after STEMI. ResultsThere were 173 and 38 patients in the normal and high E/e’ groups, respectively. During a median follow-up of 3.9 years, the primary outcome occurred in 19 patients (11.0 %) and 10 patients (26.3 %) in the normal and high E/e’ groups, respectively. The cumulative incidence of the primary outcome was higher in the high E/e’ group than in the normal E/e’ group (21.9 % vs. 7.1 % at 3 years; log-rank p = 0.013). E/e’ in the high E/e’ group decreased over time (p < 0.001), but remained higher than in the normal E/e’ group at 1 year after STEMI (13.7 ± 5.3 vs. 8.6 ± 2.3, p < 0.001). E/e’ > 14 at 1 year was also associated with poor outcomes (log-rank p = 0.008). A sensitivity analysis using multivariate Cox proportional hazards regression models yielded consistent results. ConclusionHigh E/e’ at discharge is associated with poor long-term outcomes in STEMI patients with preserved LVEF after primary PCI, which may be explained by persistent high E/e’ late after STEMI.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Efficacy of Chinese traditional patent medicines for heart failure with preserved ejection fraction: a Bayesian network meta-analysis of 64 randomized controlled trials.

Heart failure with preserved ejection fraction (HFpEF) is associated with substantial morbidity and mortality, and modern medicine offers less effective treatment for HFpEF. Much evidence shows that Chinese traditional patent medicines (CTPMs) have good efficacy for HFpEF, but the advantages and disadvantages of different CTPMs for HFpEF are still unclear. This study used network meta-analysis (NMA) to compare clinical efficacies of different CTPMs for HFpEF. Randomized controlled trials (RCTs) of CTPMs for treating HFpEF were searched in seven Chinese and English databases from inception to September 2023: China National Knowledge Infrastructure (CNKI), Wanfang, VIP, China Biology Medicine, PubMed, Cochrane Library, and Embase. Two researchers independently screened the literature, extracted data, and evaluated the quality of the included studies. The GeMTC package in R (version 4.1.2) was used to perform Bayesian NMA. A total of 64 RCTs were included, involving six CTPMs and 6,238 patients. The six CTPMs were Qili Qiangxin capsule (QLQXC), Qishen Yiqi dropping pill (QSYQDP), Yixinshu capsule (YXSC), Yangxinshi tablet (YXST), Shexiang Baoxin Pill (SXBXP), and Tongxinluo capsule (TXLC). Conventional Western medicine (CWM) treatment was given to the control group, and CWM treatment combined with CTPM treatment was given to the experimental group. The results indicated that CPTMs + CWM were all superior to CWM alone; SXBXP + CWM had the best efficacies in improving the New York Heart Association cardiac functional classification efficiency; TXLC + CWM was best at improving the ratio of early diastolic mitral inflow velocity to late diastolic mitral inflow velocity (E/A); QSYQDP + CWM was best at reducing N-terminal pro-B type natriuretic peptide (NT-proBNP); and QSYQDP + CWM was best at improving the 6-min walking test. In terms of safety, there was no significant difference between CTPMs + CWM and CWM. Compared with CWM alone, CTPMs + CWM combinations have certain advantages and good safety in the treatment of HFpEF. QSYQDP + CWM and SXBXP + CWM may be the potential optimal integrative medicine-based treatments for HFpEF. Given the limitations of this study, further high-quality, multicenter, large sample, randomized, and double-blind studies are needed to confirm the current results. identifier, CRD42022303938.

Accelerated decline in lung function is associated with cardiac structure and function and independently predicts incident heart failure

Abstract Background The association between impaired lung function and cardiovascular disease is well known. However, it is not fully understood how a decline in lung function affects the development of cardiovascular disease including heart failure (HF). Purpose We aimed to investigate the association between declining lung function and changes in cardiac structure and function. Furthermore, we investigated the association between a decline in lung function and the risk of HF. Methods The study included 2,995 participants from a general population study. All participants had two examinations with spirometry performed 10 years apart. Participants were free of valvular heart disease and HF. A subsample (n=1,164) was also examined with echocardiography at both timepoints. The decline in the forced expiratory volume in one second (dFEV1) from the first visit to the second visit, was calculated. The change in cardiac structure and function between the two visits, was calculated as the decline in left ventricular ejection fraction (dLVEF), global longitudinal strain (dGLS), left ventricular mass index (dLVMi) and the ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (dE/e’). Linear regression models were adjusted for the baseline FEV1 and echocardiographic value to account for regression to the mean. Outcome was incident HF. Results The entire sample consisted of 57% women, and the mean age was 62 ± 14 years. A total of 59% had hypertension, 8% had ischemic heart disease (IHD), 6% had diabetes, and 18% were active smokers. Mean FEV1 at baseline was 2.8 ± 0.95 liters (95 ± 19% as percentage of the predicted value). The mean decline in FEV1 between visits (median 10.8 years, IQR: 10.3-11.2) was 309 ± 362 mL. In the subsample examined with echocardiography, decreasing dLVEF was significantly associated with decreasing dFEV1 (p=0.030) in multivariable linear regression analysis, whereas dGLS, dLVMi, and dE/e’ were not. In the total study sample, 105 participants developed incident heart failure following the second visit during a median follow-up of 5.4 years (IQR: 4.5-6.3). Participants in the lowest quartile of dFEV1 (no change or increase) had an incidence rate of 2.48 per 1,000 person years (95%CI 1.33-4.60) versus participants in the highest quartile of dFEV1 (largest decline) with an incidence rate of 13.9 per 1,000 person years (95%CI 10.6-18.3), p&amp;lt;0.001. In multivariable Cox regression analysis, dFEV1 was an independent predictor of HF with a hazard ratio of 3.37 per 1 liter decline (95%CI 1.53-7.43, p=0.003). Conclusion We found a strong association between a decline in FEV1 and a decline in LVEF over a decade. Decreasing FEV1 was independently associated with incident HF. The incidence was highest for those with the largest decline in FEV1.A) Linear association B) Hist. of dLVEFA) Incidence rate B) Cumulative inc.

The classification shifting and outcomes of DELIVER-type patients with acute heart failure and preserved ejection fraction

Abstract Background The DELIVER trial enrolled subjects with acute heart failure (AHF) and preserved ejection fraction (HFpEF) who had elevated biomarkers and cardiac structural abnormalities. Given the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in AHF, it is important to understand the differences between DELIVER-type and non-DELIVER-type patients and how their classification may shift over time. Method This study enrolled patients hospitalized for AHF with LVEF ≥ 50%. Patients with elevated N-terminal pro B-type natriuretic peptide (NT-proBNP ≥ 300 or 600 pg/mL, depending on cardiac rhythm) and cardiac structural abnormalities (enlarged left atrial volume or index, or left ventricular hypertrophy) were classified as DELIVER-type. Patients who did not meet these criteria were classified as non-DELIVER-type. Patients with estimated glomerular filtration rate ≤ 25 mL/min/1.73m2 and those receiving SGLT2i treatment were excluded. Echocardiographic variables were obtained pre-discharge and one year after the index day. All-cause mortality and heart failure hospitalization up to one year were determined by web-based electronic record. Result The study included 385 subjects with an average age of 83.7 ± 13.9 years, of whom 53.2% were men. The DELIVER-type group had a higher proportion of atrial fibrillation, larger left atrial volume, thicker left ventricular wall, higher levels of the ratio of early diastolic mitral inflow velocity to early diastolic medial mitral annulus velocity (medial mitral E/e'), and higher pulmonary artery systolic pressure (PASP), as well as more evident haemoconcentration and body weight reduction during hospitalization. Kaplan-Meier curve analysis revealed higher rates of all-cause mortality and hospitalization for heart failure at one year in patients with DELIVER-type (Figure 1). In Cox regression analysis, the DELIVER-type subjects had comparable clinical outcomes after accounting for factors such as age, gender, atrial fibrillation, haemoglobin levels, and estimated glomerular filtration rate, compared to non-DELIVER subjects (hazard ratio and 95% confidence interval of mortality [1.62 (0.81-3.25)]). In one-year follow-up, 41.7% of patients shifted from non-DELIVER type to DELIVER-type, but only 14.6% of DELIVER-type subjects had classification shifting. Conclusion Non-DELIVER-type subjects had modestly lower event rates compared to those with DELIVER-type. The high proportion of classification shifting from non-DELIVER-type to DELIVER-type suggested that eligibility could vary during follow-up and that these patients could benefit from SGLT2i therapy.Baseline characteristicsClass shifting in DELIVER type

Correlation of HMGB1, TLR2 and TLR4 with left ventricular diastolic dysfunction in sepsis patients

Left ventricular diastolic dysfunction (LVDD) is a common consequence of sepsis due to dysregulated inflammatory responses. Here we aim to investigate high mobility group box 1 (HMGB1), toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) as serum biomarkers to assess LVDD risk of patients with sepsis. We recruited 120 patients with sepsis, among which 52 had ultrasonically confirmed LVDD and 68 were without LVDD. Blood samples were collected, and enzyme-linked immunosorbent assay (ELISA) was used to analyse levels of HMGB1, TLR2 and TLR4 in serum. Multivariate analysis was performed to assess the odds ratio of the serum biomarkers. Spearman's correlation analysis was conducted to evaluate the correlation between the serum biomarkers to B-type natriuretic peptide (BNP) and cardiac troponin I (cTnl) levels and the ratios of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e′ ratios) in ultrasound. Receiver operating curve was used to measure the sensitivity and specificity of HMGB1, TLR2 and TLR4 individually and in combination as diagnostic markers. Elevated HMGB1, TLR2 and TLR4 had significant values in predicting LVDD suggested by high odds ratio (all P < .05). A significant correlation was found between these values and cTnl, the current gold standard for LVDD analysis. HMGB1, TLR2 and TLR4 also showed a high diagnostic sensitivity and specificity in ROC analysis. HMGB1, TLR2 and TLR4 are potentially valuable in predicting LVDD risk among patients with sepsis, providing additional tools with the capability of potentially assisting the clinical management of patients with sepsis.

Left Ventricular Diastolic Response to Isometric Handgrip Exercise in Physically Active and Sedentary Individuals.

This study aims to investigate the diastolic left ventricular (LV) response to isometric handgrip exercise among healthy middle-aged men with high physical activity levels, versus matched sedentary individuals. Two groups of 10 men aged 41-51 years were studied. Men in the first group had high weekly self-reported physical activity levels (&gt;3000 METs × min/week). In comparison, men in the second group reported low physical activity levels (&lt;300 METs × min/week). An isometric handgrip exercise (IHE) stress echocardiography test was performed in all of them. Both groups showed a similar and statistically significant increase in heart rate, systolic, diastolic, and mean arterial pressure following IHE. The group of active men under study did not show a statistically significant change in the ratio of early diastolic mitral valve inflow velocity to early diastolic lateral wall tissue velocity (E/e' ratio) in response to IHE. Conversely, the inactive participants' E/e' ratio was higher at peak activity in the isometric handgrip exercise. Apparently, healthy middle-aged men with high levels of physical activity seem to have an improved lusitropic cardiac function compared to men with low levels of physical activity, as observed by the different diastolic LV responses induced by isometric handgrip exercise.

Effect of spironolactone on vascular stiffness in hemodialysis patients: a randomized crossover trial.

BackgroundThe role of spironolactone treatment in hemodialysis patients is debated, but a survival benefit is suggested. Mineralocorticoids and chronic kidney disease have been linked to cardiovascular fibrosis. Therefore, we hypothesized that spironolactone would affect vascular stiffness, cardiac systolic, and diastolic function in hemodialysis patients.MethodsThis was a randomized crossover study in hemodialysis patients supplemented with an echocardiographic case series. All outcomes reported here were secondary in the trial and were assessed without blinding. Block randomization and allocation determined treatment order. Participants received 50 mg spironolactone daily for 12 weeks and untreated observation for another 12 weeks. Pulse wave velocity (PWV) was measured before and after treatment and observation. Doppler-echocardiography was conducted before and after treatment. Systemic arterial compliance indexed to body surface area (SACi), left ventricular ejection fraction (LVEF), the peak early diastolic mitral inflow velocity (E), the peak late diastolic mitral inflow velocity (A), and the peak early diastolic myocardial lengthening velocity (E’) were measured. E/A and E/E’ were then calculated. Statistical analyses were conducted per protocol. A generalized linear mixed model with random participant effects was used for PWV. The Wilcoxon signed-rank test was used for echocardiographic variables.ResultsThirty participants were recruited, 18 completed follow-up, and 17 were included in PWV-analyses. Spironolactone treatment showed a tendency toward an increase in PWV of 1.34 (95% confidence interval: −0.11 to 2.78) m/s, which was not statistically significant (P = 0.07). There were no significant changes in any of the other variables (LVEF, E/A, E/Eʹ, or SACi).ConclusionsWe found no evidence supporting an effect of 12-week administration of spironolactone 50 mg daily on vascular stiffness, cardiac systolic, or diastolic function in hemodialysis patients.

Diagnostic role of echocardiography for patients with heart failure symptoms and preserved left ventricular ejection fraction.

The syndrome heart failure with preserved ejection fraction (HFpEF) represents patients with different comorbidities and specific etiologies, but with akey and common alteration: an elevation in left ventricular (LV) filling pressure or pulmonary capillary wedge pressure (PCWP). Expert consensuses, society guidelines, and diagnostic scores have been stated to diagnose HFpEF syndrome based mainly on the determination of elevated LV filling pressure or PCWP by transthoracic echocardiography (TTE). Echocardiographic parameters such as early(E) and late diastolic mitral inflow velocity (mitral E/A ratio), septal and lateral mitral annular early diastolic velocity(E'), ratio of the early diastolic mitral inflow and annular velocity (E/E'-ratio), maximal left atrial volume index (LAVImax), and tricuspid regurgitation peak velocity (VTR) constitute the pivotal parameters for determining elevated LV filling pressure or PCWP in patients with suspected HFpEF symptoms. Notwithstanding this, taking into consideration the heterogeneity of patients with HFpEF symptoms, the term "HFpEF" should be considered as asyndrome rather than an entity since HFpEF results from different pathological entities that should and can be characterized by echocardiography and multimodality imaging. Comprehensive TTE might help diagnose specific diseases and etiologies by characterization of specific cardiac phenotypes.

Effects of predilution hemodiafiltration-induced intradialytic left ventricular systolic dysfunction compared to high-flux hemodialysis.

Hemodialysis (HD)-induced myocardial ischemia may lead to left ventricular (LV) dysfunction after normal perfusion returns. This study aimed to assess the short-term influence of predilution hemodiafiltration (HDF) and high-flux hemodialysis (HD) on intradialytic LV systolic function, and hematologic and biochemical risk factors. This cross-over clinical trial enrolled 38 dialysis patients who were randomized equally into one of two treatment sequences: 1-week predilution HDF treatment followed by 1-week high-flux HD, and vice versa. LV systolic function was assessed by echocardiography before and after the mid-week dialysis session. Hematologic and biochemical parameters were also measured. Replacement fluid volume for all patients was 24.2 ± 1.3 L/session. Subjects' mean age was 53.3 ± 11.8years and 24 were males. LV ejection fraction (LVEF) decreased from 61.31 ± 9.96 to 59.03 ± 10.37% after HDF (P = 0.016), and increased from 61.69 ± 11.08 to 62.72 ± 11.26% after high-flux HD (P = 0.190). Average of peak LV systolic tissue velocity increased from 6.74 ± 1.23 to 6.98 ± 1.56cm/s after HDF (P = 0.246), and increased from 6.71 ± 1.34 to 7.44 ± 2.18cm/s (P = 0.039) after high-flux HD. The ratio between peak LV early diastolic mitral inflow velocity and peak LV early diastolic tissue velocity (E/E') at the septal mitral annulus decreased to 18 ± 9 from 21 ± 11 (P = 0.147) after HDF, and to 17 ± 8 from 20 ± 8 (P = 0.037) after high-flux HD. β2-microglobulin was reduced more during HDF than during high-flux HD (70.7 ± 5.3 vs. 67.7 ± 3.9%, P < 0.001). Predilution HDF decreases intradialytic LV systolic function more than high-flux HD. Randomized controlled trials with a larger multi-center sample and long-term follow-up are required to demonstrate the potential mechanisms of predilution HDF effecting on ventricular function.

Effect of Cerebral Ischemic Strokes in Different Cerebral Artery Regions on Left Ventricular Function.

ObjectivesThe relationship between cerebral ischemic stroke and left ventricular function evaluated by echocardiography has been emphasized. Whether lesions in different cerebral artery regions would result in left ventricular dysfunction remains uncertain.MethodsPatients were divided into middle cerebral artery (MCA) (n = 79), posterior cerebral artery (PCA) (n = 64), basilar artery (BA) regions (n = 66), and no-ischemic stroke group (n = 209). We retrospectively collected demographic characteristics, hematologic parameters, and ECG results, and a comparison of echocardiographic parameters was performed to determine the relationship between ischemic stroke and left ventricular function.ResultsA total of 418 patients were included. Demographic characteristics did not significantly differ between the ischemic stroke and non-ischemic stroke groups, except for a history of drinking (p < 0.001). Homocysteine levels in the MCA group were higher than those in the PCA and BA groups (p < 0.05). The highly sensitive C-reactive protein (hs-CRP) level was higher in the ischemic stroke group than in the non-ischemic stroke one (p = 0.001). A higher incidence of ST-T changes in the ECG and lower levels of potassium and magnesium in the ischemic stroke group were found. Significant differences in diastolic function between groups were noted, and the early mitral inflow velocity, annular early diastolic velocity, and ratio between the mitral annular early diastolic velocity and mitral annulus atrial inflow velocity in the MCA group were lower than those in the BA group (p < 0.05).ConclusionsIschemic strokes exhibited a negative effect on left ventricular diastolic function by echocardiography, especially in MCA region infarcts. These results are of great importance for neurologists as they highlight the need for left ventricular function evaluation after stroke to regulate therapy strategies in time.

Cardiac Power Output Is Independently and Incrementally Associated With Adverse Outcomes in Heart Failure With Preserved Ejection Fraction.

Cardiac power output is a measure of cardiac performance, and its prognostic significance has been shown in heart failure (HF) with reduced ejection fraction. Patients with HF with preserved ejection fraction may have altered cardiac performance, but the prognostic relevance of cardiac power output is unknown. This study sought to determine the association between cardiac power output and clinical outcomes in HF with preserved ejection fraction and to compare its prognostic effect to other measures of cardiac performance including ventricular-arterial coupling and mechanical efficiency. Cardiac power output normalized to left ventricular mass was assessed by echocardiography in 408 patients with HF with preserved ejection fraction. Load-independent contractility (end-systolic elastance), arterial elastance, its coupling (arterial elastance/end-systolic elastance), left ventricular global longitudinal strain, and mechanical efficiency (stroke work/pressure-volume area) were also estimated noninvasively. The primary end point was a composite of cardiovascular mortality or HF hospitalization. The primary composite outcome occurred in 84 patients during a median follow-up of 19.4 months. There was a dose-dependent association between cardiac power output and the composite outcomes, in which patients with the lowest tertile of cardiac power output had >3-fold risk than those with the highest tertile (hazard ratio, 3.04 [95% CI, 1.66-5.57]; P=0.0003). In a multivariable model, lower cardiac power output was independently associated with adverse outcomes (hazard ratio, 0.70 per 1 SD [95% CI, 0.49-0.97]; P=0.03). In contrast, left ventricular size, end-systolic elastance, arterial elastance, arterial elastance/end-systolic elastance ratio, and left ventricular mechanical efficiency were not associated with outcomes. Cardiac power output provided an incremental prognostic effect over the model based on clinical (age, gender, diastolic blood pressure, and atrial fibrillation) and echocardiographic markers (left atrial size, pulmonary pressures, global longitudinal strain, and the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular tissue velocity; P=0.03). In patients with HF with preserved ejection fraction, cardiac power output was independently and incrementally associated with adverse outcomes whereas other markers of cardiac performance were not.

Echocardiographic Structure and Function in Elderly Patients With Atrial Fibrillation in Japan - The ANAFIE Echocardiographic Substudy.

Echocardiographic data on the cardiac structure and function in elderly patients with atrial fibrillation (AF) and heart failure (HF) are limited. This subcohort study of the ANAFIE Registry analyzed echocardiographic parameters to identify cardiac structural and functional characteristics.Methods and Results:Of 32,726 subjects in the ANAFIE population, 1,494 (4.6%) were entered as the echocardiography subcohort. Half of the patients, including those with persistent and permanent AF, older age (≥80 years), and CHADS2score ≥2, had left atrial (LA) volume index ≥48 mL/m2, indicating severe LA enlargement. LA enlargement significantly correlated with impaired LA reservoir function, regardless of age and CHADS2score. Types of AF and rhythm were strongly related to LA volume and reservoir function (P<0.0001). Moderate-to-severe mitral and tricuspid regurgitation were significantly more common, and the early diastolic mitral inflow velocity to mitral annulus velocity ratio was significantly higher among patients with than without HF history (all, P<0.0001). In this subcohort, LA enlargement correlated with impaired LA reservoir function. Elderly patients with non-valvular AF and a history of HF had LA enlargement and dysfunction, increased LV mass index, low LV ejection fraction, and high heart rate.

Assessment of congestion and clinical outcomes in patients with chronic heart failure using shear wave elasticity.

AimsThe relief of congestion is essential for the prevention of worsening heart failure (HF) resulting in hospitalizations. Assessment of the degree of organ congestion in the chronic phase of HF is important for determining therapeutic strategies. The aim of this study was to evaluate the efficacy of shear wave (SW) elasticity for assessing congestion and clinical outcomes in patients with chronic HF.Methods and resultsWe prospectively enrolled 345 consecutive patients with chronic HF who underwent SW elastography at outpatient clinic. Patients were divided into two groups according to the median value of SW elasticity: low group (SW elasticity <6.4 kPa, n = 176) and high group (SW elasticity ≥6.4 kPa, n = 169). The endpoint was cardiovascular death or hospitalization for HF. During the median follow‐up period of 19 months (range: 7–36 months), cardiovascular death or hospitalization for HF occurred in 4 patients of low group and 27 patients of high group. In high group, 8 patients died, and 19 patients were hospitalized for HF. In low group, 3 patients died, and 1 patient was hospitalized. Kaplan–Meier analysis showed that the event‐free survival rate was worse in high group than in low group (log‐rank test, P = 0.004). After adjusting for variables, high SW elasticity was independently related to cardiac events. In multivariate regression analysis, SW elasticity was correlated with left atrial volume index, early diastolic mitral inflow velocity to mitral annular velocity ratio, and inferior vena cava diameter.ConclusionsThe SW elasticity reflected haemodynamic congestion in patients with chronic HF, which was related to cardiac events.

Peri-operative changes in diastolic function and outcomes in congenital aortic valve surgery.

BackgroundThe ratio of early diastolic mitral inflow velocity (E) to early diastolic mitral annular tissue velocity (e’), or E/e’, is an echocardiographic measure of left ventricular filling pressure. Peri‐operative changes in E/e’ and association with outcomes have been demonstrated in adults undergoing surgery for aortic stenosis (AS). We sought to explore changes in E/e’ and other diastolic indices in the setting of congenital AS surgery and to assess for association with post‐operative outcomes among children and young adults.MethodsA retrospective, single‐center study was performed among patients 6 months to 30 years of age who underwent congenital AS surgery from 2006 to 2018. Tissue Doppler indices were collected from pre‐ and post‐operative echocardiograms. Post‐operative outcomes were reviewed.ResultsSixty‐six subjects with subvalvar (45%), valvar (47%), and supravalvar (8%) AS underwent surgery at a median age of 9.5 years (IQR: 4.0–14.8). Pre‐operatively, the lateral E/e’ ratio was 8.6 (6.7–11.0); 33% had E/e’≥10. Post‐operatively, the lateral e’ decreased to 9.9 cm/s (8.0–11.4), the E/e’ ratio increased to 10.4 (8.3–13.1); and 53% had E/e’≥10 (p‐values < 0.0001, 0.0072, and < 0.001, respectively). Pre‐operative lateral e’ correlated modestly with duration of intubation (ρ = −0.24, p‐value 0.048) and post‐operative lateral e’ correlated modestly with duration of intubation and length of hospital stay (ρ = −0.28 and −0.26, p‐values = 0.02 and 0.04, respectively).ConclusionsChildren and young adults who underwent congenital AS surgery had echocardiographic evidence of diastolic dysfunction pre‐operatively that worsened post‐operatively. Lateral e’ may be a sensitive indicator of impaired ventricular relaxation in these patients and may impact duration of intubation and hospital stay.

The Thromboembolic Predictability of CHA2DS2-VASc Scores Using Different Echocardiographic Criteria for Congestive Heart Failure in Korean Patients with Nonvalvular Atrial Fibrillation.

The association between congestive heart failure (CHF) of the CHA2DS2-VASc scores and thromboembolic (TE) events in patients with atrial fibrillation (AF) is a topic of debate due to conflicting results. As the importance of diastolic impairment in the occurrence of TE events is increasingly recognized, it is crucial to evaluate the predictive power of CHA2DS2-VASc scores with C criterion integrating diastolic parameters. We analyzed 4200 Korean nonvalvular AF patients (71 years of age, 59% men) to compare multiple echocardiographic definitions of CHF. Various guideline-suggested echocardiographic parameters for systolic or diastolic impairment, including left ventricular ejection fraction (LVEF) ≤ 40%, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E’) ≥ 11, left atrial volume index > 34 mL/m2, and many others were tested for C criteria. Multivariate-adjusted Cox regression analysis showed that CHA2DS2-VASc score was an independent predictor for composite thromboembolic events only when CHF was defined as E/E’ ≥ 11 (hazard ratio, 1.26; p = 0.044) but not with other criteria including the original definition (hazard ratio, 1.10; p = 0.359). Our findings suggest that C criterion defined as diastolic impairment, such as E/E’ ≥ 11, may improve the predictive value of CHA2DS2-VASc scores.

Incremental predictive value of echocardiographic indices of right ventricular function in the assessment of long-term prognosis in dogs with myxomatous mitral valve disease

IntroductionFew studies have evaluated the utility of echocardiographic indices of right ventricular (RV) function in predicting prognosis in dogs with myxomatous mitral valve disease (MMVD). AnimalsSixty-seven client-owned dogs were diagnosed with MMVD. Materials and methodsclinical cohort study. Dogs diagnosed with American college of veterinary internal medicine (ACVIM) stage B2, C or D between April 2014 and March 2017 were enrolled. Long-term outcomes were assessed by telephone or from the medical record. The primary end-point was defined as cardiac-related death. Echocardiographic indices of RV function, including the RV Tei index, free wall and septal RV longitudinal strain, were obtained. Univariable and multivariable Cox proportional hazard analyses were used to identify variables predictive of cardiac-related death. ResultsTwenty-four dogs died during the follow-up period. The median follow-up time was 482 days, and the median survival time for dogs with cardiac-related death was 230 days. For cardiac-related death, peak early diastolic mitral inflow velocity, ACVIM stage C or D, tricuspid regurgitation velocity, RV Tei index and RV end-diastolic area were predictors in univariable Cox proportional hazard analysis. In multivariable Cox proportional analysis adjusted for the left atrial to aorta ratio, peak early diastolic mitral inflow velocity and ACVIM stage, an increase in the Tei index by 0.1 increased the hazard ratio of cardiac-related death by 33% (95% confidence interval, 16–70%; P = 0.002). ConclusionsIn dogs with MMVD, RV dysfunction assessed by the Tei index is an independent predictor of cardiac-related death.

Impact of Different Approaches to Kidney Transplant with and without Chronic Hemodialysis on Cardiac Function and Morphology: A Case-Control Study.

Patients with end-stage renal disease have higher cardiovascular morbidity and mortality compared with the general population. Preemptive kidney transplant (KTx) has been shown to be associated with improved survival, better quality of life, lower healthcare burden, and reduced cardiovascular risk. In this case–control study, we investigated the cardiovascular benefits of two approaches to KTx: with and without previous chronic hemodialysis. We enrolled 21 patients who underwent preemptive KTx and 21 matched controls who received chronic hemodialysis before KTx. Cardiac morphological and functional parameters were assessed by echocardiography. Overall, patients undergoing preemptive KTx showed less extensive cardiac damage compared with controls, as evidenced by higher global longitudinal strain, peak atrial and contractile strain, and early diastolic mitral annular velocity as well as a lower left ventricular mass, left atrial volume index, and the ratio of mitral inflow early diastolic velocity to the mitral annular early diastolic velocity. In the multivariable analysis, the presence of chronic hemodialysis prior to KTx was an independent determinant of post-transplant cardiac functional and structural remodeling. These findings may have important clinical implications, supporting the use of preemptive KTx as a preferred treatment strategy in patients with end-stage renal disease.

Vitamin D and left ventricular dysfunction in pediatric dialysis patients; a tissue doppler study.

Assessment of the left ventricular function in the dialysis children and explore its association with vitamin D level and markers reflecting calcium and phosphate metabolism. In this case-control study, we enrolled forty children on regular hemodialysis and forty healthy controls from July 2019 to March 2020 at the pediatric dialysis unit. Echocardiographic evaluation using both conventional and Tissue Doppler Imaging (TDI) was done for all subjects. Vitamin D and its markers were analyzed to assess its association with ventricular dysfunction. Diastolic function in children on hemodialysis was significantly impaired as evidenced by lower Mitral E/A velocity ratio (E/A), lower early diastolic velocity (E'), and higher E/E' ratio (Ratio of early diastolic mitral inflow velocity (measured by pulsed wave traditional Doppler) to early diastolic mitral annular velocity (measured by Tissue Doppler). in comparison with the controls. Most end stage renal disease (ESRD) participants had vitamin D deficiency. There was an important correlation between left ventricular (LV) dysfunction and both Vitamin D deficiency and hyperparathyroidism. Although our patients had normal systolic function by conventional and Tissue Doppler echocardiographic study, mean values of TDI- MPI (Mean Performance Index) in the haemodialysis group were significantly higher than in the control group, which indicates impaired global cardiac systolic and diastolic function. Tissue Doppler Imaging (TDI) provides a good reflection of the LV diastolic function. As vitamin D deficiency has been substantially associated with worsening of LV dysfunction, we suggest that TDI and Vitamin D might be included in the routine follow-up of pediatric dialysis patients.