Left Ventricular Filling Pattern Research Articles

Reproducibility of the 2016 American Society of Echocardiography-European Association of Cardiovascular Imaging Algorithm for Estimation of Left Ventricular Filling Pattern: Not Perfect but Good Enough.

The 2016 American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines for the evaluation of left ventricular diastolic function reported a new algorithm to assess diastolic function and to estimate left ventricular filling pressure (LVFP). At least five to six different parameters were necessary to conclude, each of them with their own inter-observer variability. This article examines the reproducibility of each parameter of the algorithm and its influence on the final decision of the clinician. Echocardiographic exams of 12 non-selected patients without any known cardiac disease or follow-up but addressed to the hospital for symptoms were analyzed by two readers (one junior and one senior) in five French cardiologic tertiary centers. Inter-observer reproducibility at each step of the algorithm and final decision were analyzed. There was mild agreement on the final decision. The main reasons of discrepancy were disagreement on the significance of mitral annular calcifications and measured values that are just around the cut-off (despite good reproducibility, a slight variation could lead to misclassification of a dichotomous choice between a normal measure and a pathologic measure). Without considering performance, this multicentric French study puts forward limits to the actual algorithm recommended for LVFP pattern assessment. Agreement is excellent in caricatural (easy) cases (left ventricular pressure clearly normal or clearly elevated) but a great discordance exists in the gray zone. Improvement in the algorithm and in the method for LVFP determination is proposed.

Left ventricular global longitudinal strain predicts major adverse cardiac events and all-cause mortality in heart transplant patients

Left ventricular global longitudinal strain (LVGLS) is a robust longitudinal myocardial deformation marker that is strongly affected by cardiac allograft vasculopathy (CAV), microvascular dysfunction, and acute cellular rejection (ACR). We evaluated graft deformation for risk stratification in long-term heart transplant (HTx) patients. The study included 196 patients who underwent HTx between 2011 and 2013. Patients underwent comprehensive echocardiography and coronary angiography. Previous rejection burden was assessed, and ACR grades were calculated. Patients were prospectively followed until February 24, 2016. Major adverse cardiac events (MACE), including coronary event, heart failure, treated rejection, and cardiovascular death, and all-cause mortality were recorded. During follow-up, 57 patients experienced MACE. Median follow-up was 1,035 (interquartile range [IQR] 856-1,124) days. Median time to first event was 534 (IQR 276-763) days. LVGLS was a strong predictor of MACE (hazard ratio [HR] 4.9, 95% confidence interval [CI] 2.7-8.9, p < 0.0001) in patients with and without CAV. LVGLS was a strong predictor of all-cause mortality (HR 4.9, 95% CI 2.2-10.8, p < 0.0001). Left ventricular ejection fraction (LVEF) also predicted MACE, but only in patients with CAV. No relationship between LVEF and all-cause mortality was seen. We obtained a strong MACE (HR 6.3, 95% CI 2.8-14.1, p < 0.0001) and all-cause mortality (HR 6.6, 95% CI 2.3-19.2, p < 0.0001) predictive model by combining LVGLS and restrictive left ventricular filling pattern (LVFP), which remained strong after adjustment for CAV, ACR score, hemoglobin, creatinine, and time since transplantation. Measurement of LVGLS strongly predicts MACE and mortality in long-term HTx patients. Predictive ability was seen in patients with and without CAV. A combined model of left ventricular systolic deformation by LVGLS and diastolic graft performance by LVFP was a stronger model for prediction of MACE and all-cause mortality.

Aortic Regurgitation Following Transcatheter Aortic Valve Replacement: Impact of Preprocedural Left Ventricular Diastolic Filling Patterns on Late Clinical Outcomes. DOI: 10.1002/ccd.26298.

Aortic Regurgitation Following Transcatheter Aortic Valve Replacement: Impact of Preprocedural Left Ventricular Diastolic Filling Patterns on Late Clinical Outcomes. DOI: 10.1002/ccd.26298.

Restrictive Left Ventricular Filling Pattern and Sudden Death Risk in Japanese Patients with Hypertrophic Cardiomyopathy

Restrictive Left Ventricular Filling Pattern and Sudden Death Risk in Japanese Patients with Hypertrophic Cardiomyopathy

Adverse Cardiac Events and the Impaired Relaxation Left Ventricular Filling Pattern

Increasing diastolic dysfunction (DD) grade is associated with increased heart failure (HF). Patientswith preserved ejection fractions and grade 1 DD may have left atrial dilatation, e'<8cm/sec, increased left ventricular (LV) mass, or variable E/e' ratios. The aim of this study was to test the hypothesis that LV hypertrophyor E/e' ratio>8 may be associated with a greater incidence of HF. Two hundred twelve patients with grade 1 DD and ejection fractions>50% were retrospectively studied. Group 1 comprised 108 patients with E/A ratios<0.8, without LV hypertrophy, e'<8cm/sec, and E/e' ratios<8. Group 2 comprised 104 patients with LV hypertrophy or E/e' ratios>8. Patients with incident HF and valvular or coronary disease were excluded. Using two-dimensional Doppler echocardiography, LVand left atrial volumes and transmitral spectral and tissue Doppler were analyzed. Medical records were examined for laboratory data, HF admissions, and all-cause mortality from 2004 to2012. Despite similar ejection fractions, patients in group 2 had greater LV and left atrial volumes, LV mass index values, and E/e' ratios (P<.01 for all). HF incidence was greater in group 2 (30 vs 4, P<.001). Combined HF or all-cause mortality was greater in group 2 (46 vs 14, P<.001). Multivariate analysis revealed that HF wasassociated with E/e' ratio (P<.0001), systolic blood pressure (P=.0123), and LV mass index (P=.042). Combined HF or all-cause mortality was associated with E/e' ratio (P<.0001), LV mass index (P=.009), and lower calcium channel blocker use (P=.0011). HF alone or HF and all-cause mortality were increased in patients with grade 1 DD in the presence of LV hypertrophy or elevated LV filling pressures.

Left Ventricular Restrictive Filling Pattern and the Presence of Contractile Reserve in Patients with Low‐Flow/Low‐Gradient Severe Aortic Stenosis

We sought to study diastolic function in patients with low-flow/low-gradient aortic stenosis (LF/LGAS) and to clarify the relationship between contractile reserve on dobutamine stress echocardiography (DSE) and the restrictive filling pattern on echocardiography in patients with LF/LGAS. Thirty patients with LF/LG severe AS were divided into 2 groups. Group I included 14 patients with contractile reserve on DSE. Group II included 16 patients with no contractile reserve on DSE. Diastolic function was studied in all patients using baseline echo Doppler study. No significant difference was found between both groups regarding baseline left ventriculae end-diastolic dimension (LVEDD), ejection fraction (EF), stroke volume, aortic valve area (AVA), mean transaortic pressure gradient, septal thickness or posterior wall thickness, P > 0.05. Transmitral E/A ratio was 1.3 ± 0.5 compared to 2.6 ± 0.7, respectively, deceleration time (DT) was 160 ± 31 compared to 120 ± 15 ms, isovolumic relaxation time (IVRT) was 81 ± 22 compared to 53 ± 18 ms, S/D ratio was 1.2 ± 0.3 compared to 0.8 ± 0.2, respectively, (P < 0.001 for all).Three patients in group I had restrictive pattern of diastolic dysfunction compared to 12 in group II (P < 0.003). DSE data in both groups showed a peak SV of 64 ± 11 mL compared to 50 ± 7 mL (P < 0.005), peak EF was 42 ± 9 compared to 34 ± 11% (P < 0.03). Peak stress mean transaortic pressure gradient was 39 ± 9 compared to 22 ± 10 mmHg, respectively, P < 001. Restrictive filling pattern of diastolic dysfunction on baseline echo Doppler study may predict lack of contractile reserve in patients with LF/LG severe AS.

Restrictive Left Ventricular Filling Pattern and Risk of New-Onset Atrial Fibrillation After Acute Myocardial Infarction

Mechanisms for atrial arrhythmias that occur in the context of acute myocardial infarction (AMI) have not been well characterized. AMI often leads to alterations in left ventricular (LV) filling dynamics, which may result in advanced diastolic dysfunction. Diastolic dysfunction may produce increased left atrial (LA) pressure and initiate LA remodeling, promoting the progression to atrial fibrillation (AF). We studied 1,169 patients admitted with AMI. Advanced diastolic dysfunction was defined as a restrictive filling pattern (RFP), defined as ratio of early to late transmitral velocity of mitral inflow >1.5 or deceleration time <130 ms. The relation between RFP and the primary end point of new-onset AF occurring within 6 months was analyzed using multivariable Cox models. Of 1,169 patients (70% men, mean ± SD 64 ± 10 years of age), 110 (9.4%) developed new-onset AF (19.6% and 7.5% in patients with and without RFP, respectively, p <0.0001). RFP was associated with a hazard ratio of 2.72 for AF (95% confidence interval 1.83 to 4.05, p <0.0001). After multivariable adjustments for clinical variables, LV ejection fraction (EF) and LA size, RFP remained an independent predictor of AF (hazard ratio 2.17, 95% confidence interval 1.42 to 3.32, p <0.0001). Risk of AF was higher in patients with RFP for preserved (≥45%, hazard ratio 2.14, 95% confidence interval 1.09 to 4.20, p = 0.03) or decreased (hazard ratio 2.80, 95% confidence interval 1.63 to 4.82, p <0.0001) LVEF. In contrast, decreased LVEF in the absence of RFP was similar to that of patients with preserved LVEF and without RFP. In conclusion, in patients with AMI, presence of advanced diastolic dysfunction was independently associated with new-onset AF, suggesting that increased filling pressures may contribute to the development of AF after AMI.

Letter by Razzolini and Tarantini Regarding Article, “Restrictive Left Ventricular Filling Pattern Does Not Result From Increased Left Atrial Pressure Alone”

To the Editor: We congratulate Masutani and colleagues1 on their insightful article distinguishing a restrictive filling pattern due to an overfilled normal left ventricle from one due to a failing enlarged left ventricle. We do not think, however, that the differences …

Response to Letter Regarding Article, “Restrictive Left Ventricular Filling Pattern Does Not Result From Increased Left Atrial Pressure Alone”

We are grateful for the interest in our article1 expressed by Razzolini and Tarantini. They agree that we have demonstrated that the restrictive filling is not due to an overfilled ventricle. However, they are concerned that this pattern is not due to diastolic dysfunction but instead results from systolic dysfunction. Although restrictive filling is most common in patients with heart failure associated with a …

Restrictive Left Ventricular Filling Pattern Does Not Result From Increased Left Atrial Pressure Alone

The restrictive filling pattern seen with severe heart failure (HF) may be due to diastolic dysfunction with elevated left ventricular (LV) diastolic pressure or may be merely a manifestation of an overfilled LV as a result of increased left atrial (LA) pressure. We investigated whether the LV restrictive filling pattern is due to elevated LA pressure alone. We studied conscious dogs instrumented to measure LA pressure, LV pressure, and 3 LV diameters. LV filling dynamics were evaluated in 2 situations with similar elevations of LA pressure: in normal animals after rapid volume loading with dextran 500 mL and in animals with pacing-induced HF with restrictive filling. With HF, there was increased LV chamber stiffness and slow relaxation. Volume loading and HF had similar heart rates (129+/-19 versus 131+/-15 bpm) and LA pressure (22.1+/-5.8 versus 22.6+/-3.3 mm Hg). The peak early filling rate (E) was increased with both HF and volume loading. However, in HF, the peak mitral annular velocity (E') was decreased and delayed, and the E deceleration time was shorter. In contrast, with volume loading, E' was increased and not delayed. The restrictive filling pattern is distinguished from overfilling of a normal ventricle by a reduced and delayed E' and a shortened E deceleration time that reflect slow relaxation and increased LV stiffness.

Impact of Septal Myectomy on Left Atrial Volume and Left Ventricular Diastolic Filling Patterns: An Echocardiographic Study of Young Patients with Obstructive Hypertrophic Cardiomyopathy

Septal myectomy in young patients with obstructive hypertrophic cardiomyopathy (HCM) can be performed with low mortality, and leads to excellent improvement in symptoms. Left atrial (LA) enlargement has been associated with exercise intolerance, severity of mitral regurgitation (MR), and left ventricular (LV) outflow tract (LVOT) obstruction in adults with HCM. Young patients (1-22 years of age) who had a septal myectomy for obstructive HCM between 2002 and 2005 were identified. Retrospective analyses of premyectomy and postmyectomy echocardiograms were performed. In this cohort of 32 patients (25 male), the average maximal LV wall thickness was 25 +/- 9 mm and LVOT maximal instantaneous gradient was 106 +/- 44 mm Hg. MR was present in all patients with a mean grade of 3 +/- 1. All patients had successful myectomy and there were no early deaths. After myectomy, LVOT maximal instantaneous gradient decreased to 17 +/- 13 mm Hg (P < .0001). Mean LA volume (LAV) index decreased from 52.1 +/- 2.2 to 33.2 +/- 11.9 mL/m(2) (P < .0001). Mean MR grade decreased to 2 +/- 1. Early mitral medial annular tissue Doppler velocity (E') increased from 6.2 +/- 1.9 to 13 +/- 2.6 cm/s (P < .043). A postmyectomy decrease in LAV index correlated with decrease in LVOT obstruction (P = .001) and change in degree of MR (P = .04). Septal myectomy not only reduces LVOT maximal instantaneous gradient and MR in young patients, but also results in decreased LAV index, and E/A and E/E' ratios. These hemodynamic improvements may contribute to the observed survival benefit and increased exercise tolerance observed after myectomy. This is the first series to demonstrate that LAV correlates closely with hemodynamic status in children with obstructive HCM and may be a significant predictor of clinical outcome in these patients.

Left Ventricular Diastolic Filling Pattern at Doppler Echocardiography and Apoptotic Rate in Fatal Acute Myocardial Infarction

Heart failure is a complex syndrome characterized by impaired emptying and/or impaired filling of the heart chambers. The use of parameters of diastolic function has provided novel tools for risk stratification and management of patients with heart failure. This study evaluated the potential correlation between apoptosis at time of death and left ventricular (LV) diastolic function after acute myocardial infarction. We selected, at routine postmortem examination, 14 subjects who died 10 to 62 days after an acute myocardial infarction and had an available echocardiographic report from the most recent hospital admission. The apoptotic rate was calculated at the region bordering the infarct, using co-localization of in situ end-labeling for deoxyribonucleic acid fragmentation and immunohistochemistry for caspase-3. Transthoracic echocardiographic studies were retrospectively reevaluated and pulse-wave Doppler spectra of mitral inflow were analyzed. LV diastolic function was assessed by measuring the ratio of E peak velocity to A peak velocity and E-wave deceleration time; a ratio of E peak velocity to A peak velocity >or=2 and deceleration time <115 ms were considered a restrictive filling pattern. A restrictive pattern was found in 4 cases (29%). All subjects with a restrictive pattern were symptomatic for New York Heart Association class IV heart failure (100% vs 20%, p = 0.015) and had larger transverse heart diameters at pathology (p = 0.014). The apoptotic rate in the peri-infarct region was significantly higher in patients with a restrictive versus nonrestrictive diastolic pattern (13%, 10 to 14, vs 3%, 1 to 6, p = 0.014). At multivariable analysis that included the restrictive pattern, class IV heart failure, and cardiac diameters, the restrictive pattern remained an independent predictor of increased apoptosis (p = 0.030). In conclusion, patients with severe postinfarction LV diastolic dysfunction had significantly higher rates of cardiomyocyte loss by apoptosis, which may partly explain their unfavorable outcome.

Predictive Value of C-Reactive Protein and Left Ventricular Diastolic Filling Pattern after a Non-ST Elevation Myocardial Infarction

Recent studies have shown that the odds ratio for high-sensitivity C-reactive protein (CRP) in predicting a coronary events in healthy subjects is 1.4, a value substantially less than previously reported. It is unclear whether this extends to acute coronary syndrome patients or if CRP would predict long-term events in this population. We evaluated the predictive value of CRP in patients with non-ST segment elevation myocardial infarction (NSTEMI) as their first manifestation of coronary artery disease and compared it with that of left ventricle diastolic function. Serum CRP concentration measurement and left ventricle diastolic function evaluation were performed in 51 consecutive patients with NSTEMI 48 hours, 3 months, and 6 months after infarction. Patients were followed for 1 year and events comprising the endpoints of death, new myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting were reported. Thirty of 51 patients developed the endpoints. Mean CRP concentration in patients who developed any endpoint and those who did not was similar at 48 hours, 3 months, and 6 months. A strong correlation between the presence of impaired relaxation 6 months after the infarction and development of the combined endpoints was noted (P < 0.001). CRP has limited value in predicting future cardiovascular events in subjects with NSTEMI. Other biomarkers or a combination of other biomarkers may be needed to identify patients at high risk. Evaluation of diastolic left ventricular function not during the acute phase but 6 months later could predict adverse outcome in our series.

Single-beat Differentiation Among Left Ventricular Filling Patterns by Pulsed Wave Doppler Echocardiography

We sought to evaluate whether the combination of phantom E wave peak velocity (Ep) to phantom A wave peak velocity (Ap) ratio at the apex (Ep/Ap) and pulsed wave Doppler left ventricular (LV) inflow propagation velocity (LVIPVpw) or the combination of Ep/Ap and Ep/LVIPVpw obtained from the same heartbeat can effectively differentiate LV filling patterns. The study population included 132 patients. They were classified into normal, abnormal relaxation, and pseudonormal/restrictive groups according to the ratio of early to late transmittal filling wave peak velocity (E/A), color M-mode Doppler LV inflow propagation velocity, and E/color M-mode Doppler LV inflow propagation velocity. Standard Doppler parameters of LV filling such as E, A, E/A, and E-wave deceleration time had a bimodal distribution, but LVIPVpw decreased and Ep/LVIPVpw increased progressively with worsening of LV diastolic function (both P < .001). The sensitivity and specificity of combination of Ep/Ap 1 or greater and LVIPVpw less than 77 cm/s or of Ep/Ap 1 or greater and Ep/LVIPVpw greater than 0.87 from the same heartbeat in identifying the pseudonormal/restrictive LV filling pattern were 81% and 95% or 81% and 93%, respectively. In conclusion, with application of range ambiguity phenomenon, it is simple and feasible to differentiate LV filling patterns on the same cardiac cycle by pulsed wave Doppler echocardiography.

Survival in Thalassaemia Major Patients Prognostic Value of Doppler-Demonstrated Left Ventricular Restrictive Filling Pattern

The present study evaluated the prognostic significance of Doppler-demonstrated left ventricular (LV) restrictive filling pattern (RFP) in patients with thalassaemia major (TM), which carries an adverse cardiovascular prognosis. The study group comprised 45 asymptomatic transfusion-dependent patients with TM and normal LV systolic function. All patients were chelated with desferrioxamine. They were regularly evaluated by clinical and Doppler-echocardiographic studies throughout the 15-year follow-up period. The patients were categorized into 2 groups according to baseline data: those with LVRFP and those with LV non-RFP. The incidence of cardiac death in both groups was analyzed. The impact of chelation therapy on the ventricular filling pattern and survival was also examined. Nineteen patients (42.2%) had LVRFP and 26 (57.8%) had LV non-RFP. During follow-up 11 patients died from cardiac causes; 8 of them (72.8%) initially had LVRFP and 3 (27.2%) had LV non-RFP. LVRFP was significantly associated with mortality (p=0.018). Poor compliance with chelation therapy was significantly associated with LVRFP (p=0.007) and cardiac mortality (p=0.003). LVRFP is an important predictor of cardiac mortality in patients with TM. Poor compliance with chelation therapy was significantly associated with both a RFP (p=0.007) and cardiac mortality (p=0.003).

An Echocardiographic Analysis of the Long‐Term Effects of Carvedilol on Left Ventricular Remodeling, Systolic Performance, and Ventricular Filling Patterns in Dilated Cardiomyopathy

The long-term clinical benefit of beta blockade is well recognized, but data quantifying long-term effects of beta blockade on remodeling of the left ventricle (LV) is limited. This consecutive series evaluates the long-term response of the LV to the addition of carvedilol to conventional therapy for dilated cardiomyopathy. There were 33 patients who had a LV ejection fraction <45%, LV enlargement and symptomatic heart failure. Quantitative Doppler echocardiography was performed at baseline 6, 12, 24, and 36 months after initiation of carvedilol to evaluate LV ejection fraction, LV volume, wall stress, mass, regional function, and diastolic performance. Compared to baseline there was a significant and sustained reduction in end-systolic volume and end-systolic wall stress with a corresponding improvement in LV ejection fraction. The LV mass did not decline but relative wall thickness increased toward normal. An analysis of regional wall motion responses showed an improvement in all areas, particularly the apical, septal, and lateral walls that was significantly more frequent in patients with a nonischemic etiology. Filling patterns of the LV remained abnormal throughout the study but changed with therapy suggesting a decline in filling pressures. These changes were sustained for 3 years. (1) The addition of carvedilol to conventional therapy for a dilated cardiomyopathy significantly improves LV ejection fraction and reduces LV end-systolic volume and wall stress for at least 3 years, (2) the response to 6 months of treatment predicts the long-term response, (3) the typical response is partial improvement of the LV, complete return to normal size, and function is uncommon, and (4) abnormalities of LV filling persist in virtually all patients throughout the course of treatment.

Predictors of Cardiovascular Death in Patients with a Left Ventricular Restrictive Filling Pattern of the Mitral Inflow

The survival, clinical and echocardiographic variables and the predictors of cardiovascular death were determined for a group of 168 patients (mean age 63 ± 13 years; 65 females; mean left ventricular ejection fraction 32 ± 10%) with restrictive filling of the left ventricle and depressed systolic function after a mean follow-up period of 2.7 ± 1 years. Shorter deceleration time (DT) of the mitral inflow was the only variable significantly different between survivors and nonsurvivors (p < 0.05) and the only predictor of death found by multivariate logistic regression analysis (odds ratio 2.2, 95% confidence interval 1.7–3.6). In this patient population, a DT of the early wave of the mitral inflow <140 ms identified the patients with the highest risk of cardiac death. DT is a practical echocardiographic parameter for risk stratification of patients with significant left ventricular systolic dysfunction and restrictive filling of the left ventricle.

Restrictive Left Ventricular Filling Pattern with Preserved Systolic Function Assessed by Doppler Echocardiography: Clinical, Echocardiographic and Prognostic Implications

From an echocardiographic laboratory database, echocardiographic characteristics of clinical and cardiovascular mortality were compared in patients with restrictive pattern of left ventricular filling (RPLVF) and left ventricular ejection fraction (LVEF) >50% (n = 36), with patients with RPLVF and LVEF <50% (n = 120) and echocardiographic controls (n = 160). Preserved LVEF was found in 21% of the patients with RPLVF. Mortality in patients with RPLVF was worst compared with echocardiographic controls regardless of their underlying LVEF after 2.7 ± 1 years of follow-up. Patients with RPLVF had distinctive predictors of cardiovascular death, with clinical and echocardiographic characteristics according to their LVEF.

Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction: Predictive Significance of Left Ventricular Diastolic Filling Pattern

Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction: Predictive Significance of Left Ventricular Diastolic Filling Pattern

Changes in left ventricular filling pattern during dobutamine stress Doppler echocardiography.

To study the left ventricular filling pattern during stress Doppler echocardiography and its utility in the detection of myocardial ischaemia. Fifty-seven consecutive patients underwent dobutamine stress echocardiography. The left ventricular filling pattern (E-wave velocity; A-wave velocity; E/A ratio; E-wave deceleration time) was analysed at baseline and at maximum heart rate reached. The percentage increase in these parameters from baseline to peak heart rate was also determined. Myocardial ischaemia (regional contractility worsening) was induced in 19 cases (ischaemic group) but not in 38 cases (non-ischaemic group). There were no differences between both groups at baseline. E-wave deceleration time decreased in the non-ischaemic group (197+/-63 vs. 167+/-65 ms, P=0.01) and increased in the ischaemic group (203+/-42 vs. 315+/-135 ms, P<0.0001). A percentage increase in E-wave deceleration time of >30% showed a positive predictive value of 93% and a negative predictive value of 86% for detecting ischaemia, and in the multivariate analysis it was the only Doppler parameter (P<0.0001) that predicted the induction of ischaemia. We conclude that myocardial ischaemia provokes an increase in E-wave deceleration time. Analysis of left ventricular filling could help in the identification of those cases which are positive for ischaemia.