Peak Early Diastolic Mitral Inflow Research Articles

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.

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.

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.

Value of Index Beat in Evaluating Left Ventricular Systolic and Diastolic Function in Patients with Atrial Fibrillation: A Dual Pulsed-Wave Doppler Study

Atrial fibrillation (AF) poses challenges in use of the echocardiogram to assess left ventricular (LV) function. The index beat method has been found to agree well with the average method. We aimed to assess the value of the index beat method in evaluation of LV function using the dual pulsed wave Doppler technique. Peak early diastolic mitral inflow velocity (E) and diastolic (e′) and systolic (s′) mitral annulus velocity were simultaneously obtained and measured beat-to-beat in patients with AF. The index beat s′ exhibited the best correlation (r = 0.96 and 0.92, respectively, for septal and lateral wall, both p values = 0.000) with the mean, while E/e′ at the pre-index beat, rather than at the index beat-initiated cycle, had the best correlation with the mean (r = 0.88 for septal and 0.97 for lateral wall, both p values = 0.000).

The change of left ventricular function and mechanical dispersion in patients with hypertrophic cardiomyopathy: a study with exercise stress echocardiography

Objective To investigate the association between the change of left ventricular (LV) function and mechanical dispersion (MD) and exercise capacity in patients with hypertrophic cardiomyopathy (HCM) by exercise stress echocardiography. Methods Sixty-five HCM patients [40 cases of hypertrophic non-obstructive cardiomyopathy (HNCM), 25 cases of hypertrophic obstructive cardiomyopathy (HOCM)] and 25 control subjects were recruited.LV function, MD and exercise capacity were evaluated by two-dimensional speckle-tracking imaging and echocardiography at rest and during exercise, and the following parameters of LV function were recorded: LV global longitudinal strain (LVGLS), MD, early diastolic strain rate (SRe), the ratio of peak early diastolic mitral inflow and annulus velocity (E/e′), LV outflow tract gradient (LVOTG); LV functional reserve was assessed by ΔLVGLS and ΔSRe; exercise capacity was evaluated by metabolic equivalents (METs). The association between the change of LV function and MD and exercise capacity was investigated. Results ①Compared with normal controls, LVOTG, E/e′ and MD increased, and LVGLS, SRe, ΔLVGLS, ΔSRe and METs decreased in HNCM patients at rest and during exercise (all P<0.05). ②LVOTG, E/e′ and MD were further increased, LVLGS, SRe, ΔSRe and METs were further reduced in HOCM patients compared with HNCM patients (all P<0.05). ③LVGLS and MD measured at peak exercise were associated with METs(r=-0.68, P<0.001; r=-0.43, P<0.001). ④ROC curve analysis showed LVGLS had a better predictive value for exercise intolerance in HCM patients, followed by E/e′ and MD. Conclusions LV function and mechanic reserve are reduced but MD is increased in HCM patients, especially in HOCM patients. Exercise capacity is associated with LV function and MD, which can predict the reduced exercise capacity in HCM patients. Key words: Exercise stress echocardiography; Two-dimensional speckle-tracking imaging; Cardiomyopathy, hypertrophic; Ventricular function, left; Mechanical dispersion

Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications

ObjectivesThis study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction. BackgroundAn AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity. MethodsIn 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity/peak early diastolic mitral annular velocity ratio (E/e′) <14, a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) and blood assays for biomarkers were performed. Echocardiography following maximal exercise was undertaken to assess AbnDR (exertional E/e′ >14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death. ResultsAbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e′ (odds ratio [OR]: 8.23; 95% confidence interval [CI]: 3.54 to 9.16; p < 0.001), left ventricular untwisting rate (OR: 0.60; 95% CI: 0.42 to 0.86; p = 0.006), and galectin-3—a marker of fibrosis (OR: 1.80; 95% CI: 1.21 to 2.67; p = 0.004). The use of resting E/e′ >11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34; p = 0.95). ConclusionsThe implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e′ followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of individuals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test.

Early changes of left atrial structure and function in patients with obstructive sleep apnea syndrome

Objective To investigate the early changes of left atrial structure and function using echocardiography in obstructive sleep apnea syndrome(OSAS) patients with and without left ventricular hypertrophy(LVH). Methods Echocardiography was performed in 91 OSAS patients (64 without LVH, 27 with LVH), and the results were compared with those from age-matched and gender-matched controls (n=40). All subjects were examined with two-dimensional speckle tracking echocardiography (2D-STE) to obtain the apical four chamber and two chamber left atrium(LA) strain and strain rate curve image. Systolic strain and strain rate(Ss, SRs), early diastolic strain and strain rate(Se, SRe), late diastolic strain and strain rate(Sa, SRa) were measured. Phasic LA volumes and empty fractions were calculated. The ratio of peak early diastolic mitral inflow and annulus velocity(E/e′) was used to estimate left ventricular diastolic function. Results Compared with the control group, LA volume, LA stiffness index, SRa and active empyting fraction (AEF) increased, Ss, SRs, Se, SRe, total empyting fraction (TEF) and passive empyting fraction (PEF) decreased in none LVH group (P 0.05). Diastolic function decreased in LVH group, and the changes of left atrial structure and function like above mentioned were more significant.The apnea-hypopnea index (AHI) was found to be negatively correlated with Ss, SRs, Se, SRe, TEF and PEF. Conclusions OSAS is associated with LA remodeling and dysfunction that occurs before the development of LVH and left ventricular diastolic dysfunction, and it will be further aggravated along with the development of LVH. Key words: Two-dimensional speckle tracking imaging; Sleep apnea, obstructive; Atrial function, left

Echocardiographic Predictors of Pulmonary Embolism: Return to Old Parameter

SESSION TITLE: Venous Thromboembolism SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Transthoracic echocardiography (TTE) offers diagnostic clue and hemodynamic status in patients with pulmonary embolism (PE). Many indices have been suggested to play a useful diagnostic role. This study aimed to certify peak early diastolic mitral inflow velocity (E velocity) as diagnostic predictors of PE in patients who underwent chest computed tomography (CT) scanning for rule out PE. METHODS: During the period of January 2013 to May 2014, we enrolled a total of 131 consecutive patients (44.3% men, mean age 71±13 years) as following inclusion criteria: 1) Underwent chest embolism CT for the stated indication of rule out PE, 2) Underwent contemporary TTE within 48 hours interval, 3) Pulmonary arterial systolic pressure (PASP) ≥ 30 mmHg, using peak tricuspid regurgitation (TR) velocity. The patients were divided into two groups; 1) PE group (n=43), who was diagnosed as submassive or massive PE by chest CT scanning, 2) Non-PE group (n=88), who didn’t have an evidence of PE in chest CT scanning; and the clinical and echocardiographic parameters were compared between two groups. RESULTS: Baseline clinical characteristics were not different between two groups. The PE group had significantly lower mitral E velocity (56.61±19.02 vs. 85.16±28.29 cm/s, P<0.001), E/A ratio (0.62±0.16 vs. 1.26±0.92, P<0.001), E/E’ ratio (11.0±4.0 vs. 17.1±9.2, P<0.001). PASP (48.8±13.7 vs. 43.3±13.7 mmHg, P=0.03) and peak TR velocity (3.09±0.52 vs. 2.89±0.50 mmHg, P=0.036) were higher in the PE group. In multivariate regression analysis, mitral E velocity was independent predictor in diagnosis of PE (HR 0.955, 95% CI 0.929-0.983, P=0.002). The cut-off value of mitral E velocity (AUC 0.808, 95% CI 0.731-0.885, P<0.001) for diagnosis of PE was < 68.2 cm/s (Sensitivity 69.3%, Specificity 81.4%). CONCLUSIONS: These results suggest that the peak transmitral E velocity would be important adjunctive predictor for diagnosis of PE, which maybe related with left ventricular underfilling. CLINICAL IMPLICATIONS: This study certified the peak early diastolic mitral inflow velocity (E velocity) as a simple diagnostic predictor of pulmonary embolism. DISCLOSURE: The following authors have nothing to disclose: Chan-Hee Lee, Hyun Jung Kim No Product/Research Disclosure Information

Left Atrial Strain at Different Stages of Myxomatous Mitral Valve Disease in Dogs.

BackgroundDecreased function of the left atrium (LA) is a useful prognostic indicator in dogs with myxomatous mitral valve disease (MMVD). In humans, LA strain is a novel severity indicator of mitral regurgitation, but its clinical utility in dogs has not been confirmed.ObjectivesTo examine whether LA strain as evaluated with speckle‐tracking echocardiography is associated with MMVD stage in dogs.AnimalsFifty‐two client‐owned dogs with MMVD.MethodsCross‐sectional study. Dogs were classified as stage B1, B2, C, or D, according to the American College of Veterinary Internal Medicine consensus. Physical examination findings and echocardiographic variables were compared among the groups. To assess the comparative accuracy of echocardiographic variables in identifying dogs with the presence or history congestive heart failure (CHF), receiver operating characteristic curves and multivariate logistic analysis were used.ResultsThere were no significant differences in parameters of LA strain between B1 and B2 groups. However, LA longitudinal strain during atrial contraction (εA) (median, 19.1%; interquartile range, 15.3–24.3% in B1, 19.6%; 14.1–21.4% in B2, 6.2%; 3.18–11.2% in C/D) and during ventricular systole (εS) (32.7%; 28.9–39.2% in B1, 35.6%; 31.7–41.9% in B2, 23.6%; 16.9–26.1% in C/D) were significantly lower in stages C/D than in stages B1 and B2. In multivariate logistic regression analysis, εA and peak early diastolic mitral inflow velocity were identified as independent indicators of stage C/D.Conclusions and Clinical ImportanceεA was the best predictor of the presence or history of CHF. Further studies are needed to determine the clinical implications of these findings for treatment decisions and prognosis determination.

Prognostic Value of Right Ventricular Tei Index in Dogs with Myxomatous Mitral Valvular Heart Disease.

BackgroundThe right ventricular (RV) Tei index (TX) has a significant correlation with the severity of pulmonary hypertension. However, the role of RV dysfunction in dogs with myxomatous mitral valvular heart disease (MMVD) has not been addressed.ObjectivesTo investigate the correlation between right ventricular Tei‐index (RVTX) and the prognosis for dogs with MMVD.AnimalsThirty client‐owned dogs with MMVD.MethodsClinical cohort study. Dogs were divided into two groups on the basis of the onset of cardiac‐related death within 1 year of the first echocardiographic examination. Physical examination and echocardiographic variables were compared between the groups. Receiver operating characteristic (ROC) curves and multivariate logistic analysis were used to assess the comparative accuracy when identifying dogs with cardiac‐related death.ResultsThe highest accuracy was obtained for RVTX with an area under the ROC curve (AUC) of 0.95 (95% confidence interval [CI] 0.81–0.99) followed by the left atrial to aortic root ratio with an AUC of 0.91 (95% CI 0.74–0.98), peak early diastolic mitral inflow velocity with an AUC of 0.84 (95% CI 0.64–0.94), and Doppler estimates of systolic pulmonary artery pressure with an AUC of 0.84 (95% CI 0.61–0.95). According to the multivariate logistic regression analysis, RVTX was the only independent correlate of cardiac‐related death within 1 year.Conclusions and Clinical ImportanceRight ventricular Tei‐index has a strong correlation with the prognosis for dogs with MMVD. The most significant independent predictor of death was RVTX in this study.

Prognostic value of left atrial function in dogs with chronic mitral valvular heart disease.

BackgroundA strong correlation between left atrial (LA) dysfunction and the severity of cardiac disease has been described in human patients with various cardiac diseases. The role of LA dysfunction in dogs with chronic mitral valvular heart disease (CMVHD) has not been addressed.ObjectivesTo investigate the correlation between LA function and the prognosis of dogs with CMVHD.AnimalsThirty‐eight client‐owned dogs with CMVHD.MethodsProspective clinical cohort study. Dogs were divided into 2 groups (survivors and nonsurvivors) based on the onset of cardiac‐related death within 1 year. Physical examination and echocardiographic variables were compared between the groups. For the assessment of the comparative accuracy in identifying patients with cardiac‐related death, receiver operating characteristic (ROC) curves and multivariate logistic analysis were used.ResultsThe highest accuracy was obtained for the LA active fractional area change (LA‐FAC act), with an area under the ROC curve (AUC) of 0.95, followed by the left atrial to aortic root ratio (LA/Ao), with an AUC of 0.94; peak early diastolic mitral inflow velocity (E), with an AUC of 0.85; and LA total fractional area change (LA‐FAC total), with an AUC of 0.85. In the multivariate logistic regression analysis, LA‐FAC act emerged as the only independent correlate of cardiac‐related death within 1 year (odds ratio = 1.401, P = .002).Conclusions and Clinical ImportanceRegarding both the size and function, the LA has a strong correlation with the prognosis of dogs with CMVHD. The most significant independent predictor of mortality in this study was LA‐FAC act.

Evaluation of left atrial function in hypertensive patients with and without left ventricular hypertrophy using velocity vector imaging.

To study left atrial deformation characteristics using Velocity vector imaging (VVI) in hypertensive patients with and without left ventricular hypertrophy (LVH), and to explore its value for detection of left atrial dysfunction in these patients. Sixty-four patients with essential hypertension were divided into normal left ventricular geometry (LVN, 37 cases) and LVH (27 cases) groups, according to their left ventricular mass index. Twenty-five age-matched healthy participants were included as control group. Two-dimensional dynamic images of the apical four- and two-chamber echocardiographic views were obtained, and strain/strain rate (SR) curves of eight atrial segments were derived by VVI software. Peak systolic strain (ε(sys)), systolic SR (SRs), early and late diastolic SR (SRe, SRa) were measured and calculated. Peak early diastolic mitral inflow and annulus velocities were also measured and their ratio (E/E') calculated. Compared with the control group, SRe decreased and SRa increased significantly in LVH group (P < 0.05), while no significant difference was found between LVN and control groups with respect to SRe, SRa, SRs and ε(sys) (P > 0.05). Also, no significant difference was observed in SRe, SRa, SRs and ε(sys) between LVH and LVN groups (P > 0.05). SRe and SRa correlated significantly with E/E' (r = -0.634, r = 0.609; both P < 0.001). Strain/SR parameters derived from VVI may reflect decreased conduit, increased booster pump function of the left atrium in hypertensive patients with LVH and correlate with left ventricular diastolic function.

Speckle Tracking-Derived Mitral Annular Velocities Predict Mortality in Patients with Acute Coronary Syndrome

Myocardial ischemia can impair myocardial relaxation and result in increased left ventricular (LV) diastolic pressure. Noninvasive measurements of mitral annular velocities have been used to evaluate LV diastolic pressure. We sought to determine whether mitral annular velocities, derived from novel speckle tracking echocardiography (STE), could predict mortality in patients with acute coronary syndrome (ACS). A total of 246 patients with ACS were retrospectively studied. STE was analyzed offline with the sample volume placed on septal, lateral, inferior, and anterior mitral annulus. Peak early (E') and late (A') diastolic velocities of the mitral annulus were measured and averaged from the four regions. Peak early diastolic mitral inflow velocity (E) was obtained using pulsed-wave Doppler. Lower E' (P = 0.03), lower A' (P = 0.001), higher E'/A' ratio (P = 0.007), and higher E/E' ratio (P = 0.003) were independently associated with increased risk of death with adjustment for clinical and echocardiographic variables over the follow-up period of 21 months. The optimal cutoff value of E/E' ratio derived from the receiver operating characteristic analysis for predicting death was 30 (area under the curve = 0.65). E/E' ratio greater than 30 was predictive of death in univariate (HR, 2.40; CI, 1.42-4.06; P = 0.001) and multivariate (adjusted HR, 1.91; CI, 1.09-3.32; P = 0.02) models. The measurements of mitral annular velocities by STE are predictive of mortality in patients with ACS.

Prognostic Value of Tricuspid Annular Tissue Doppler Velocity in Heart Failure with Atrial Fibrillation

Right ventricular function is associated with long-term outcomes of heart failure (HF), particularly with atrial fibrillation (AF). The aim of this study was to evaluate the prognostic value of Doppler tissue imaging at the mitral and tricuspid annuli in patients with HF and AF. In this prospective observational study, 457 patients (mean age, 67 years; 283 men) referred for HF with AF were enrolled and underwent conventional echocardiography including pulsed-wave Doppler tissue imaging. Systolic (s') and early diastolic (e') velocities of the tricuspid and mitral annuli were recorded from the apical four-chamber view. The development of clinical adverse events during the follow-up period was defined as the composite of cardiac death and readmission for HF. During the follow-up period (median, 20 months), 37 patients reached the primary end point (nine deaths and 28 cases of HF). Patients with cardiac events were significantly older and more often had previous HF admissions and diuretic use, higher New York Heart Association classes, and greater average ratios of peak early diastolic mitral inflow to annular velocity. Additionally, Doppler tissue imaging of s' and e' at the tricuspid, septal, and lateral mitral annuli were all reduced. Multivariate analysis showed that tricuspid s' and septal e' remained significant predictors of cardiac events. By Kaplan-Meier analysis, the occurrence of cardiac events was more frequent when tricuspid s' was <9.0 cm/sec (P < .001) and when septal e' was <7.3 cm/sec (P < .001). In patients with HF and AF with a high risk for cardiac events, tricuspid s' and septal e' can be independent risk predictors of outcomes.

Cardiac benefits of renal artery stenting

The aims of this study were to evaluate the effects of renal stenting on cardiac function using echocardiographic parameters, and to clarify whether changes in clinical and echocardiographic variables after renal stenting differ between atherosclerotic renal artery stenosis (ARAS) patients with and without cardiac symptoms. A total of 61 patients who underwent renal stenting and echocardiography were included in the study. Left ventricular (LV) filling pressure and LV relaxation were evaluated with tissue Doppler imaging. The ratio of the peak early diastolic mitral inflow velocity to the peak early mitral annular velocity (E/e' ratio) and the e'-velocity were measured to assess diastolic function. LV ejection fraction remained unchanged, but the E/e' ratio (P<0.001) and the e'-velocity (P=0.004) improved after renal stenting. In particular, the E/e' ratio improved from 13.7±5.6 to 11.9±4.0 (P=0.002) within 24 hours after renal stenting and remained low at 11.2±3.8 after a mean follow-up period of 7±4 months (P=0.001). Patients with cardiac symptoms showed significantly better change in E/e' ratio (P=0.002) and E-velocity (P=0.005) compared to those without cardiac symptoms. Cardiac symptoms also significantly improved after renal stenting (New York Heart Association functional class: 2.5±0.6 at baseline to 1.4±0.6 at follow-up; P<0.001). Renal stenting improved echocardiographic parameters that reflect LV diastolic function, and yielded a higher benefit for E/e' ratio and E-velocity in patients with cardiac symptoms than in those without cardiac symptoms.

Exercise and Weight Loss Improve Exercise Capacity Independent of Cardiac Function in Metabolic Syndrome

Hypertension, diabetes and obesity cause cardiac diastolic dysfunction (DD) which could reduce exercise capacity. Our aim was to determine if 10% weight loss by exercise at 60% VO(2max) five days/week (approximately -375 kcal/session) and caloric restriction (approximately -600 kcal/d) over 6 months improves exercise capacity and DD in Metabolic syndrome (MetS). Eighteen subjects (40 +/- 1y, women = 6, BMI = 33.5 +/- 1.0 kg/m(2)) successfully completed the study. Maximal treadmill stress echocardiography was performed at baseline and post weight loss to determine VO(2max), resting and stress DD as the ratio of peak early diastolic mitral inflow velocity (E) to tissue Doppler early diastolic annular decent (E'). After weight loss (mean = 9.5 +/- 0.2%), all metabolic parameters improved. Resting and stress E/E' values remained normal before and after weight loss. Exercise intolerance is likely due to general deconditioning and not cardiac dysfunction in early MetS as VO(2max) increases significantly with lifestyle while cardiac function remains unchanged.

Abstract 4868: Subendmyocardial Perfusion Reserve Correlated with Left Ventricular Diastolic Function in Patients with Various Types of Left Ventricular Hypertrophy

Reduced myocardial perfusion reserve (MPR) and left ventricular (LV) diastolic dysfunction were frequently observed in patients with LV hypertrophy (LVH). The purpose of this study was to determine the relationship between MPR assessed by stress-rest perfusion MRI and LV diastolic function in patients with various types of LVH. In patients with diastolic heart failure (DHF, n=34), hypertrophic cardiomyopathy (HCM, n=28), hypertensive LVH (n=42), cardiac amyloidosis (n=4), and control subjects (n=46), stress-rest perfusion MR images were acquired with saturation recovery balanced TFE sequence. Blood input and myocardial output curves were analyzed to determine absolute myocardial blood flow (MBF). MPR were quantified in subendocardial (subend) and subepicardial (subepi) sides of LV wall. LV diastolic function was evaluated using echocardiography, and peak early diastolic mitral annular velocity (Ea) and the ratio of peak early diastolic mitral inflow to Ea (E/Ea) were obtained. MBF at rest was 1.08 mg/ml/min and, subend and subepi MPR were 3.5 and 3.6 in control subjects. To compare with control subjects, subend MPR tended to be decreased in LVH, subend MPR was decreased in DHF, subend and subepi MPR were decreased despite preserved subend and subepi MBF in HCM, and both subend and subepi MBF as well as MPR were decreased in cardiac amyloidosis. According to the disease subgroup, Ea and subend MPR showed a significant correlation(r=0.95), and E/Ea and subend MPR showed an inversed correlation (r=−0.97). (Figure 1 ) Subend MPR significantly correlated with LV diastolic function in patients with various types of LVH.

Prognostic Implications of the NT-ProBNP Level and Left Atrial Size in Non-Ischemic Dilated Cardiomyopathy

The ratio of peak early diastolic mitral inflow to annular velocity (E/E') and left atrial size could provide prognosis on congestive heart failure (CHF). N-terminal Pro B-type natriuretic peptide (NT-ProBNP) has also been useful for predicting adverse cardiac events. However, it is not clear how these parameters compare with conventional risk factors. Thus, we investigated whether E/E', left atrial dimension index (LADI) and NT-ProBNP would predict adverse events and add incremental value to conventional risk factors, even in non-ischemic advanced dilated cardiomyopathy (DCM). Both NT-ProBNP and echocardiography were evaluated in 105 patients. The cardiac events were defined as the composite of cardiac death and re-admission for CHF. At follow up, cardiac events occurred in 24 patients who had high NT-ProBNP and showed higher LADI and E/E'. In multivariate analysis, both NT-ProBNP and LADI, but not E/E', remained as independent predictors; patients with both increased LADI and NT-ProBNP had a 27-fold higher risk of cardiac events than those without any risk factors (p = 0.003). Moreover, LADI and NT-ProBNP showed a better incremental prognostic value over conventional risk factors (global chi-square increase from 7 to 17 to 49, p = 0.003, p < 0.001, respectively). Both NT-ProBNP and LADI might have the most predictable power, particularly in non-ischemic advanced DCM.

Usefulness of Tissue Doppler Parameters for Identifying Pulmonary Embolism in Patients With Signs of Pulmonary Hypertension

The objective of this study was to use tissue Doppler parameters to identify pulmonary embolism (PE) in patients with echocardiographic signs of pulmonary hypertension. One hundred fifty patients with echocardiographic signs of pulmonary hypertension were enrolled, 50 of whom had PE on multidetector row computed tomography of the chest. Another 150 patients without cardiopulmonary distress or echocardiographic signs of pulmonary hypertension served as a control group. All patients were in sinus rhythm. Routine echocardiography and tissue Doppler imaging were performed. The right ventricular (RV) myocardial performance index (MPI) was obtained during tissue Doppler imaging over the lateral tricuspid annulus. The M index was measured and defined as the peak early diastolic mitral inflow velocity divided by the RV MPI. Statistical analysis was preformed using receiver-operating characteristic curves. Peak early diastolic mitral inflow velocity was significantly less and the RV MPI was significantly greater in patients with PE than in patients without PE (both p values < 0.0001). The RV MPI and the M index were useful in identifying PE in patients with echocardiographic signs of pulmonary hypertension. On statistical analysis, a RV MPI > 0.55 identified PE with a sensitivity of 85% and a specificity of 78%. A M index < 112 had a sensitivity of 92% and a specificity of 92%. In conclusion, the sensitivity and specificity of the RV MPI and the M index to identify PE were excellent. Echocardiography is a useful method to screen for PE.

Dynamic determinants of left ventricular early diastolic filling in old myocardial infarction.

The determinants of left ventricular early diastolic filling were assessed in 15 patients with old myocardial infarction. The left atrial pressure (LAP) and left ventricular pressure (LVP) were simultaneously measured by a Millar's multisensor micromanometer with the pusled Doppler mitral inflow velocity at baseline and during angiotensin infusion (20 ng/kg/min). Cardiac output was measured by a thermodilution method. LV peak systolic pressure and end-diastolic pressure were significantly (p less than 0.001) increased during angiotensin infusion from 137 +/- 19 to 170 +/- 21 mmHg and from 13.3 +/- 5.9 to 20.4 +/- 6.2 mmHg, respectively. Cardiac index was significantly decreased during angiotensin infusion. Heart rate, diastolic time, and peak positive dP/dt were unchanged. Although the LA-LV peak pressure gradient[(LAP-LVP) max] was unchanged (from 2.8 +/- 1.0 to 3.0 +/- 1.4 mmHg), the pressure gradient interval (the interval between the first and second points of transmitral pressure crossover) was significantly (p less than 0.001) decreased from 154 +/- 38 to 117 +/- 26 msec during angiotensin infusion. Peak early diastolic mitral inflow velocity (peak E) and the time-velocity integral of E wave (Ei) were significantly decreased during angiotensin infusion from 51 +/- 10 to 45 +/- 11 cm/sec (p less than 0.002) and from 7.47 +/- 1.96 to 5.70 +/- 1.66 cm (p less than 0.001), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)