Mitral Annulus Tissue Doppler Velocities Research Articles

Abstract 4138624: Looking Beyond Respirophasic Ventricular Interdependence: A Case Report of Constrictive Pericarditis Masquerading as Cirrhosis

Case Presentation: A 67-year-old man with recurrent pleural effusions and concern for cirrhosis was referred for liver transplant. Pleural fluid was transudative by Light’s criteria with a high total protein level of 3.5 g/dL, which made hepatic hydrothorax unlikely. Liver biopsy confirmed congestive hepatopathy without advanced fibrosis. Transthoracic echocardiogram showed left ventricular (LV) ejection fraction 55%, right ventricular (RV) systolic pressure 35 mmHg, normal mitral annular tissue doppler velocities, and early diastolic septal bounce. Right and left heart catheterization showed prominent X and Y descent, elevated and equalized diastolic pressures, but no respiratory discordance in the LV-RV pressure gradient. As etiology of these findings were unclear, he underwent aggressive diuresis and hemodialysis, but repeat right heart catheterization showed persistently elevated right and left filling pressures. Cardiac MRI had no evidence of myocardial or pericardial inflammation/edema but showed pericardial thickening (7.9 mm) and septal bounce. There was no inspiratory septal shift, but the large pleural effusion appeared to limit diaphragm excursion. Given lack of respirophasic ventricular interdependence and thickened pericardium on MRI, CT was ordered, showing pericardial calcifications. Diagnosis of constrictive pericarditis was made, and patient underwent complete pericardiectomy. Pathology confirmed calcified and thick pericardium without acute inflammation. Post-operatively, patient developed RV failure, but recovered with inotrope support and was discharged with improvement in congestive symptoms. Discussion: Constrictive pericarditis classically exhibits respirophasic ventricular interdependence, but large pleural effusions may decrease respiratory variation in intrathoracic pressures, blunting this response. Normal mitral annulus tissue doppler velocities and lack of infiltrative process on cardiac MRI made restrictive cardiomyopathy unlikely. In the absence of respirophasic changes on multimodality testing, constriction can be diagnosed with other supportive features such as diastolic septal bounce, rapid Y descent, diastolic pressure equalization, and pericardial thickening and calcifications.

Hemodynamic determinants of left atrial strain in patients with hypertrophic cardiomyopathy: A combined echocardiography and CMR study.

BackgroundLeft atrial (LA) strain is associated with symptomatic status and atrial fibrillation in patients with hypertrophic cardiomyopathy (HCM). However, hemodynamic determinants of LA reservoir (LARS), conduit, and pump strains have not been examined and data are needed on the relation of LA strain with exercise tolerance in HCM.MethodsFifty HCM patients with echocardiographic and CMR imaging within 30 days were included. Left ventricular (LV) volumes, mass, EF, scar extent, extracellular volume fraction (ECV), and LA maximum volume were measured by CMR. Echo studies were analyzed for mitral inflow, pulmonary vein flow, mitral annulus tissue Doppler velocities, LV global longitudinal strain, and LA strain. Twenty six patients able and willing to exercise underwent cardiopulmonary stress testing for peak oxygen consumption (MVO2), and VE/VCO2 slope. Patients were followed for clinical events.FindingsLARS was significantly associated with indices of LA systolic function, LV GLS, and LV filling pressures (P<0.05). Conduit strain was significantly associated with mitral annulus early diastolic velocity and ECV, whereas LA pump strain was determined by LA systolic function and indices of LV end diastolic pressure (all P<0.05). LARS and conduit strain were significantly higher in patients who achieved ≥80% of MVO2. LARS, conduit, and pump strains were significantly associated with atrial fibrillation (P<0.05).ConclusionsLV structure, systolic and diastolic function, and LA systolic function determine the 3 components of LA strain. LA strain is associated with exercise tolerance and clinical events in patients with HCM.

Study of the Usefulness of Echocardiographic Indexes in the Assessment of Effectiveness of Dehydration in a Dialysis Session

Purpose In patients with end-stage renal disease, dialysis leads to changes in systolic and diastolic function of the heart. The purpose of this study is to determine which echocardiographic indexes shows the greatest variability during heamodialysis including the TEI index (myocardial performance index) and which of these may be useful in assessing the efficacy of dehydration of a dialysis session. Methods 16 adult patients (9 males, mean age 64,625 ± 13,865 years) with chronic end-stage renal failure undergoing a standard 3-week dialysis session comprised the study population. Peak E wave velocity of transmitral flow, E / A and E / e ratio, mitral annulus tissue doppler velocities, aortic valve flow velocity integral (MeanPG) and tissue doppler imaging derived TDI TEI index were assessed under stable conditions before and following dialysis session. In the second part of the study, the study population was 10 adults (6 women, mean age 72±8.65 years) who were randomly assigned to a dialysis session for the first time in our clinic without a previous history of dialysis. They underwent consecutive ultrasound measurements during dialysis. Changes in E/e ratio were determined per 500ml of dehydration and correlated with changes in lower ventricular diameter, which is a standard indicator of the efficacy of dehydration in a dialysis session. Results Dialysis resulted in a reduction of a peak E wave of the tansmitral flow (p = 0.068), in a reduction of the E/A ratio (p =0.117) and a significant decrease in the E/e ratio (13.95 ± 4.8 versus 10.65 ± 3.36, p =0.032) which reflects the decrease of the left ventricular end-diastolic filling pressure. The E/e ratio changed by 23.26% in the chronic dialysis patients and this appeared to be the case after 2.3 Kg of dehydration as calculated in the second sample of 10 patients. No significant changes in mean aortic valve pressure gradient (p = 0.556) and mitral annulus tissue doppler velocities (p=0.563) were observed. The TEI tissue index did not show statistically significant changes in its values after dialysis (p =0.672). Conclusions Effective dehydration in a dialysis session leads to a significant reduction in the left ventricular filling of the left ventricular pressure as demonstrated by the change in the E/e ratio, which appears to be a useful tool for assessing the effectiveness of dehydration of a dialysis session.

Echocardiographic Assessment of Cardiac Performance in Response to High Altitude and Development of Subclinical Pulmonary Edema in Healthy Climbers

BackgroundData regarding the effect of high altitude on heart function are sparse and conflicting. We aimed to assess the right and left ventricular responses to altitude-induced hypoxia and the occurrence of subclinical pulmonary edema. MethodsEchocardiography was performed according to protocol on 14 subjects participating in an expedition in Nepal, at 3 altitude levels: Montreal (30 m), Namche Bazaar (3450 m), and Chukkung (4730 m). Systematic lung ultrasound was performed to detect ultrasound lung comets. ResultsPulmonary artery systolic pressure increased in all subjects between Montreal and Chukkung (mean 27.4 ± 5.4 mm Hg vs 39.3 ± 7.7 mm Hg; P < 0.001). Right ventricular (RV) myocardial performance index (MPI) increased significantly (0.32 ± 0.08 at 30 m vs 0.41 ± 0.10 at 4730 m; P = 0.046). A trend toward deteriorated RV free wall longitudinal strain was observed between Montreal and Chukkung (−25.9 [5.3%] vs −21.9 [6.4%]; P = 0.092). The left ventricular early diastolic inflow velocity/atrial mitral inflow velocity and early diastolic inflow velocity/mean of the maximal early diastolic mitral annulus tissue doppler velocities ratios remained unchanged. At 4730 m, ultrasound lung comets were seen in all subjects except 1. None had clinical criteria for high-altitude pulmonary edema (HAPE). All altered parameters normalized after return to sea level. ConclusionSubclinical HAPE is frequent in healthy lowlander climbers. This is the first study to document a trend towards decreased RV free wall strain and MPI increment at high altitude. Whether rising RV MPI is a physiologic adaptive mechanism to hypoxia or a pathologic response identifying HAPE-susceptible subjects needs further study.

Aortic Elastic Properties Are Related to Left Ventricular Diastolic Function in Patients with Type 1 Diabetes Mellitus

Objective: The aim of the study was to evaluate left ventricular diastolic function and its relation to aortic wall stiffness in patients with type 1 diabetes mellitus without coronary artery disease or hypertension. Patients: Sixty-six patients with type 1 diabetes mellitus were examined by echocardiography and divided into two groups according to the diastolic filling pattern determined by mitral annulus tissue Doppler velocities. Group A patients (n = 21) presented diastolic dysfunction with a peak early diastolic mitral annular velocity (Em)/peak late diastolic mitral annular velocity (Am) ratio <1 whereas in group B patients (n = 45) the Em/Am ratio was >1. Coronary artery disease was excluded based on normal thallium scintigraphy. Aortic stiffness index was calculated from aortic diameters measured by echocardiography, using accepted criteria. Results: Aortic stiffness index differed significantly among the two groups. Significant correlations were found between parameters of left ventricular diastolic function (Em/Am, isovolumic relaxation time, deceleration time) and aortic stiffness index. Multiple stepwise linear regression analysis revealed aortic stiffness index (β = –0.39, p = 0.001) and isovolumic relaxation time (β = –0.46, p < 0.001) as the main predictors of Em/Am ratio. Conclusions: Aortic stiffness is increased in type 1 diabetic patients with left ventricular diastolic dysfunction. This impairment in aortic elastic properties seems to be related to parameters of diastolic function.

Stroke Volume and Mitral Annular Velocities: Insights from Uremic Patients with Significant Valvular Regurgitation

This study investigates the change in new diastolic indices in uremic patients who undergo regular hemodialysis (H/D). We studied uremic patients receiving regular H/D. All patients were sinus rhythm before H/D. They had normal left ventricular systolic performance without regional wall motion abnormality. Patients were separated into two groups according to whether they had significant aortic or mitral regurgitation (AR or MR) or not. They received complete transthoracic echocardiographic examinations. Stroke volume (SV) was calculated as the product of the time-velocity integral (TVI) and cross-sectional area of aortic annulus. Flow propagation velocity (FPV) was measured by color M-mode echocardiography in apical four-chamber view. Mitral annulus tissue Doppler velocities--peak systolic (Sa), early diastolic, and late diastolic--were measured from septal and lateral wall. All these parameters were obtained immediately before and after H/D. Paired data were compared. H/D amount was strongly correlated with the change of SV. After H/D, the reduction of SV in patients without AR or MR (control group) was obvious but it was not significant in patients with significant AR or MR (study group). There were significant differences in mitral inflow velocities, FPV, and mitral annular velocities (except septal Sa) in the control group. In the study group, predialytic and postdialytic parameters of new diastolic indexes had no statistical difference. New echocardiographic indexes of uremic patients with significant AR or MR were relatively preload-independent. The phenomenon was possibly related to insignificant change of SV after H/D.

Assessment of left ventricular diastolic function with Doppler tissue imaging: effects of preload and place of measurements.

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 +/- 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E', A') from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p < 0.001, p = 0.007, p < 0.001, respectively) after hemodialysis. Mitral annulus E' wave velocities and E'/A' ratios obtained from five different sides of the annulus also changed significantly (p < 0.001 for all); however, there was no change in the A' wave velocity (p > 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E' velocities and E'/A' ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E', r = 0.329, p = 0.009 and E'/A' ratio, r = 0.286, p = 0.04; for septal side E', r = 0.376, p = 0.003 and E'/A' ratio, r = 0.297, p = 0.019; for anterior side E', r = 0.342, p = 0.007 and E'/A' ratio, r = 0.268, p = 0.035; for posterolateral side E', r = 0.423, p = 0.001 and E'/A' ratio, r = 0.343, p = 0.007; and for inferior side E', r = 0.326, p = 0.01 and E'/A' ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.