Peak Reverse Flow Velocity Research Articles

Pioglitazone improves ventricular diastolic function in patients with diabetes mellitus: A tissue Doppler study

Objective — Pioglitazone treatment in type 2 diabetes mellitus produced significant improvements in glycaemic control, plasma lipids, blood pressure and inflammation. The aim of this study was to investigate the effect of pioglitazone on systolic and diastolic function in diabetic patients.Methods and results — Forty-nine diabetic patients were included in the study.The patients had never received thiazolidinedione therapy before. Clinical and echocardiographic variables were measured. 30 mg pioglitazone were administered. The patients were followed up for six months and all the measurements were re-evaluated for comparison. Body mass index (BMI) significantly increased after treatment. Fasting glucose, HbA1c and systolic blood pressure decreased. Insulin resistance improved and the HOMA-IR index decreased after pioglitazone treatment. Mean aortic diameter, left atrial systolic and diastolic volumes significantly decreased after therapy. Among diastolic function variables mitral E wave, E/A, ejection time and pulmonary vein peak reverse flow velocity (PVA) significantly increased whereas isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), deceleration time, E/E’ and pulmonary vein late systolic flow (PVS2) decreased after pioglitazone therapy. Among tissue Doppler variables early (E) ventricular inflow velocities measured from the tricuspid lateral annulus, the mitral septal and lateral annulus, the anterior, inferior and posterior free wall significantly increased. Late (A) ventricular inflow velocities measured from the anterior, inferior free wall and the mitral septal annulus also increased.Conclusion — Pioglitazone treatment in type 2 diabetes mellitus produced significant improvements in measures of glycaemic control and diastolic ventricular function.

Pioglitazone improves ventricular diastolic function in patients with diabetes mellitus: a tissue Doppler study.

Pioglitazone treatment in type 2 diabetes mellitus produced significant improvements in glycaemic control, plasma lipids, blood pressure and inflammation. The aim of this study was to investigate the effect of pioglitazone on systolic and diastolic function in diabetic patients. Forty-nine diabetic patients were included in the study. The patients had never received thiazolidinedione therapy before. Clinical and echocardiographic variables were measured. 30 mg pioglitazone were administered. The patients were followed up for six months and all the measurements were re-evaluated for comparison. Body mass index (BMI) significantly increased after treatment. Fasting glucose, HbA1c and systolic blood pressure decreased. Insulin resistance improved and the HOMA-IR index decreased after pioglitazone treatment. Mean aortic diameter, left atrial systolic and diastolic volumes significantly decreased after therapy. Among diastolic function variables mitral E wave, E/A, ejection time and pulmonary vein peak reverse flow velocity (PVA) significantly increased whereas isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), deceleration time, E/E' and pulmonary vein late systolic flow (PVS2) decreased after pioglitazone therapy. Among tissue Doppler variables early (E) ventricular inflow velocities measured from the tricuspid lateral annulus, the mitral septal and lateral annulus, the anterior, inferior and posterior free wall significantly increased. Late (A) ventricular inflow velocities measured from the anterior, inferior free wall and the mitral septal annulus also increased. Pioglitazone treatment in type 2 diabetes mellitus produced significant improvements in measures of glycaemic control and diastolic ventricular function.

Lung Tissue Blood Perfusion Changes Induced by in utero Tracheal Occlusion in a Rabbit Model of Congenital Diaphragmatic Hernia

Objective: To analyze the impact of in utero tracheal occlusion (TO) on lung tissue blood perfusion, as measured by fractional moving blood volume (FMBV) and conventional spectral Doppler, in a rabbit model of congenital diaphragmatic hernia (CDH). Methods: In 50 fetal rabbits, a left CDH was surgically created at 23 days of gestational age (GA). At 28 days of GA, the surviving CDH fetuses were randomly assigned to undergo either TO (CDH+TO group) or a sham operation (CDH group). Twenty littermates, which were not operated on, served as internal normal controls. At 30 days of GA, lung perfusion estimated by FMBV and spectral Doppler of the proximal intrapulmonary artery were evaluated in the right lung during cesarean section. Doppler waveform analysis included the pulsatility index (PI), peak early diastolic reverse flow and peak systolic velocity. Results: Eleven CDH fetuses, 9 CDH+TO and 20 controls were suitable for the study. CDH fetuses showed a significantly higher PI [8.0 (SD 1.8) vs. 5.22 (SD 1.1), p < 0.001] and lower FMBV [13.5% (SD 4.6) vs. 23.0% (SD 2.1), p < 0.001] than the controls. In contrast, CDH+TO fetuses had a significantly lower PI [5.8 (SD 2.3) vs. 8.0 (SD 1.8), p = 0.015] and higher FMBV [27.6% (SD 7.1) vs. 13.5% (SD 4.6), p < 0.001] than CDH fetuses, with values similar to the controls. Peak early diastolic reverse flow and peak systolic velocity showed nonsignificant differences among the study groups. The lung to body weight ratio at necropsy correlated positively with lung FMBV (r = 0.60, p < 0.001) and negatively with the pulmonary artery PI (r = –0.48, p < 0.01). Conclusion: Tracheal occlusion is consistently associated with increased lung tissue perfusion and decreased intrapulmonary impedance in a rabbit model of CDH.

2416: The influence of respiration on the Doppler waveform of the right hepatic vein in right-lobe living donor liver transplantation recipients

Objectives: To determine the influence of respiration on Doppler waveform of right hepatic vein (RHV) in right-lobe living donor liver transplantation (LDLT). Methods: Doppler spectra of RHV in 14 consecutive normal right-lobe LDLT recipients were repeatedly obtained without breath-hold, with breath-hold at end expiration and with breath-hold at full inspiration within 3 cm of IVC, and were reviewed to determine their waveforms. Peak forward flow velocity (PFFV), peak reverse flow velocity (PRFV) and venous pulsatility index (VPI, PFFV/PRFV) were compared among three groups using repeated measures ANOVA. Results: The waveforms of RHVs without breath-hold and with breath-hold at end expiration were triphasic in 13 of 14 (92.8%) patients and biphasic in one (7.2%). However, the waveforms with breath-hold at full inspiration were monophasic in five (35.7%), biphasic in one (7.2%) and triphasic in eight (57.1%). PRFV (23.5± 13.4, 21.9± 14.1 and 39.7± 25.4 at full inspiration, p = .001) and VPI (0.35 ± 0.19, 0.34 ± 0.17 and 0.60 ± 0.32, p = .001) showed significant differences. Conclusions: The pulsatility of RHV can be reduced with breath-hold at full inspiration and triphasic pattern can be changed into monophasic one without complication in right-lobe LDLT recipients. Therefore, patient’s breath-hold at full inspiration should be avoided when obtaining Doppler spectra of RHV in right-lobe LDLT recipients.

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease.

We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.

Prognostic Implications of Doppler-derived Indexes of Pulmonary Venous Flow after Acute Myocardial Infarction

Background and Objectives:Doppler indexes of pulmonary venous flow (PVF) have been recognized to be useful in defining left ventricular filling characteristics, but their long-term prognostic value in patients with acute myocardial infarction (AMI) is not clear. The purpose of this study was to determine the prognostic significance of Doppler indexes of PVF after AMI. Subjects and Methods:Doppler echocardiographic examination was performed in 122 patients with AMI between 7 to 10 days after attack, and followed for 30 months. Peak systolic velocity (PVs), peak diastolic velocity (PVd), and peak reverse flow velocity associated with atrial contraction (PVa) of PVF were measured by transthoracic echocardiography. End-points were cardiac death or readmission due to congestive heart failure (re-CHF). Results:There were 9 deaths (7.4%) and 13 patients with re-CHF (10.7%) during the follow-up period. Patients with events had higher PVa (p=0.039). Subgroup analysis of patients with E/A ratio >1 showed that they had lower PVs/PVd ratio (p=0.029) and higher PVa (p=0.069). Event-free survival was significantly lower in patients with PVs/PVd ratio 1. Conclusion:PVa and PVs/PVd ratio of PVF were helpful indexes in predicting the prognosis in patients with AMI and an E/A ratio of >1. (Korean Circulation J 2003;33 (6):491-498)

Assessment of the Left Atrial Appendage Mechanical Function by Three-Dimensional Echocardiography

Aims: We evaluated the feasibility of three-dimensional echocardiography, in the assessment of left atrial appendage (LAA) function. Methods and Results: Forty-five patients underwent multiplane transoesophageal echocardiography. In addition to Doppler and two-dimensional echocardiography, data for three-dimensional echocardiography reconstruction were obtained during transoesophageal echocardiography. Left atrial appendage ejection fraction based on three-dimensional echocardiography volume measurements (EFv) and two-dimensional echocardiography area measurements (EFa), coupled with other echocardiographic data, were related to left atrial appendage late peak emptying velocity, a frequently used indicator of left atrial appendage function. Multiple regression analysis has revealed a significant association of peak emptying velocity with EFv ( P <0·0001), spontaneous echocardiographic contrast ( P =0·001), tricuspid regurgitation ( P =0·03) and left ventricular hypertrophy ( P =0·05). No significant relation was observed between peak emptying velocity and EFa, presence or absence of atrial fibrillation, left ventricular dysfunction, mitral stenosis and insufficiency, left atrial dilatation, pulmonary venous peak systolic, diastolic and peak reverse flow velocity at atrial contraction as well as left atrial appendage volumes derived from two-dimensional echocardiography and three-dimensional echocardiography. In a simple linear correlation, the degree of association between peak emptying velocity and EFv was higher as between peak emptying velocity and EFa (r=0·7 vs 0·4, both P <0·001). Observer variabilities for calculating EFv were considerably lower than for two-dimensional echocardiography derived EFa. Ejection fractions determined by two-dimensional echocardiography area measurements at 45°, 90° and 135° cutplane angulations were related to EFv only at 135°. Conclusions: Left atrial appendage ejection fraction calculation by three-dimensional echocardiography is feasible, more accurate than by two-dimensional echocardiography and has lower observer variability. Furthermore, an optimal cutplane angulation of the left atrial appendage view at 135° has been demonstrated. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

The Influence of Obesity on Chronic Venous Disease

The authors investigate the impact of overweight in patients with chronic venous disease and determine if the eventual effect can be explained by increased venous reflux alone. Patients with chronic venous disease who underwent duplex-ultrasound scanning at the Vascular Center, Straub Clinic and Hospital during 1999 were classified according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and body mass index (kg/m(2)) was calculated. Reflux duration was measured in seconds and peak reverse flow velocity in cm/second. Multi-segment reflux score (total score) was calculated for both reflux duration and peak reverse flow velocity. The reflux pattern and body mass index were correlated to the clinical presentation. Four hundred and one lower extremities (204 right, 197 left) in 272 patients (173 female) with a mean age of 60 years (range 14-90) were investigated. The mean body mass index was 28.9 (+/-7.76). One hundred sixty-seven patients (61%) were overweight (body mass index 25 kg/m(2) or more). There was a significant association between body mass index and the clinical severity (p<0.001). This association persisted after adjustments for total peak reverse flow velocity and total reflux score were made (p<0.001). Overweight patients were more likely to have skin changes and ulceration (p<0.001) than patients with a body mass index less than 25 kg/m(2), despite similar values for total reflux time (p=0.92) and total peak reverse flow velocity (p=0.98). There was an ethnic difference, with Pacific Islanders being significantly heavier and younger compared to patients of white, Asian and Filipino ancestries. The variations in the frequency of skin changes were consistent with ethnic differences in body mass index. The correlation of body mass index with clinical severity independent of reflux measurements indicates that the effect of overweight may involve a mechanism separate from local effects on venous flow. Overweight appears to be a separate risk factor for increased severity of skin changes in patients with chronic venous disease.

Pulmonary venous flows reflect changes in left atrial hemodynamics during mitral balloon valvotomy.

Patients with mitral stenosis have usually blunted pulmonary venous (PV) flow, because of decreased mitral valve area and diastolic dysfunction. The authors compared changes in Doppler PV velocities by using transesophageal echocardiography (TEE) against hemodynamics parameters before and after mitral balloon valvotomy to observe relevance of PV velocities and endsystolic left atrial (LA) pressure-volume relationship. In 25 patients (aged 35 +/- 17 years) with mitral stenosis in sinus rhythm, changes in LA pressure and volumes were compared with PV velocities before and after valvotomy. Mitral valve area, mitral gradients, and deceleration time were obtained. Mitral valve area and mitral gradients changed from 1 +/- 0.2 cm2 and 14.6 +/- 5.4 mmHg to 1.9 +/- 0.3 cm2 and 6.3 +/- 1.7 mmHg, respectively (p<0.001). AR peak reverse flow velocity and AR duration decreased from 29 +/- 13 cm/s and 110 =/- 30 msec to 19 +/- 6 cm/s and 80 +/- 29 msec respectively (p<0.001). Transmitral Doppler E wave deceleration time decreased from 327 +/- 85 to 209 +/- 61 s and cardiac output increased from 4.2 +/- 1.0 to 5.2 +/- 1.1 L/minute (p<0.001). The changes in LA pressure were correlated with changes in S/D (r=0.57, p<0.05). The changes in endsystolic LA pressure-volume relationship were also correlated with changes in S/D (r=0.52, p<0.05). Endsystolic LA pressure-volume relationship decreased after mitral balloon valvotomy, as a result of a large decrease in pressure. PV systolic/diastolic (S/D) waves ratio reflects endsystolic LA pressure-volume relationship and may be used as another indicator of successful valvotomy.

Remodeling and Changes of Systolic and Diastolic Functions of Left Ventricle after Acute Myocardial Infarction: Comparison according to Killip Class at Admission

Background:Infarct size determines left ventricular (LV) systolic and diastolic dysfunctions after acute myocardial infarction, and also may affect the recovery from functional impairment. We studied the differences of LV remodeling and changes of systolic and diastolic functions of LV during two weeks after acute myocardial infarction, according to Killip class at admission. Methods:Echocardiographic examinations were performed within two days (23.9±2.3 hours), and two weeks after the attack in 27 patients with acute myocardial infarction, and the results were compared with those of 19 controls. Patients were divided into two groups according to Killip class at admission;18 patients in Killip class I (group I) and 9 patients in Killip class II to IV (group II). Group II had larger infarct, reflected by higher levels of peak serum cardiac enzymes. Results:LV systolic function was more depressed in group II. Regional wall motion score index decreased in group I after two weeks, but not in group II. LV systolic and diastolic volume indexes increased after two weeks in group II but not group I. E/A ratio of mitral inflow was less than 1, and isovolumic relaxation time was prolonged in group I immediately after the attack. Group II had E/A 1 and shorter deceleration time (DT) of mitral inflow, and higher peak reverse flow velocity associated with atrial contraction (AR) of pulmonary venous flow than those of controls immediately after the attack. In group II, E/A ratio was greater, DT was shorter, peak systolic/diastolic flow velocity ratio of pulmonary venous flow was less, and AR was higher than those of controls after two weeks. Conclusion:Infarct size affected remodeling and changes of systolic and diastolic functions of LV after acute myocardial infarction. In patients with large infarct, LV was dilated and regional wall motion was not improved during two weeks. Restrictive pattern of LV filling, which was more aggravated during two weeks, was noted immediately after the attack. In patients with small infarct, LV was not dilated and regional wall motion was improved during two weeks. LV filling pattern showed relaxation abnormality. (Korean Circulation J 1998;28 (10):1727-1739)

Evaluation of left ventricular diastolic function by pulmonary venous and mitral flow velocity patterns in endurance veteran athletes

More and more older people exercise endurance training. Physical activity regularly exercised has been proven to exert beneficial effects on the cardiovascular system. The aim of the present study was to investigate left ventricular diastolic function by analysis of the pulmonary venous flow velocity pattern (PVFVP) in conjunction with the mitral flow velocity pattern (MFVP) in endurance veteran athletes. The study was performed in 15 trained veteran athletes (mean age 60 +/- 10) and 15 sedentary older subjects (mean age 61 +/- 7). Between the two groups there were no differences of age, body surface area and blood pressure. All subjects were without evidence of cardiovascular diseases. They underwent transthoracal pulsed Doppler echocardiography and the following parameters were measured: early (E) and late (A) peak diastolic filling velocities from mitral flow and E/A ratio; peak forward flow velocities during systole (S) and diastole (D) and peak reverse flow velocity at atrial contraction (Ar) from right upper pulmonary vein. The peak early diastolic filling and E/A ratio resulted significantly increased in the veteran athletes compared with the older sedentary subjects (E 80.0 +/- 13.6 and 62.2 +/- 8.2, respectively, p < 0.01; E/A 1.20 +/- 0.1 and 0.90 +/- 0.1, respectively, p < 0.001), whereas there were no significant differences m the PVFVP between the two groups. Heart rate at rest was significantly lower in the veteran athletes compared with sedentary older subjects (58.3 +/- 8 and 72.8 +/- 7.6, respectively, p < 0.001). These data demonstrate an improvement of left ventricle diastolic function in endurance veteran athletes (E/A ratio > 1 ) in comparison with sedentary older subjects (E/A ratio > 1). Analysis of PVFVP suggests that the left atrial contribution to left ventricular filling increases with aging without any significant differences between the two groups. Therefore, left atrial function, i.e., the main determinant of PVFVP is not likely influenced by training. In conclusion, physical activity was found to attenuate alterations in the cardiovascular system that occur in advanced age by an improvement of left ventricular diastolic filling. These changes at rest may be due to a decreased sympathetic tone, as well as to an improvement of intrinsic properties of myocardium of the endurance veteran athletes.

Pulmonary venous flow velocity pattern as assessed with transthoracic pulsed Doppler echocardiography in subjects without cardiac disease

Pulmonary venous flow velocity pattern (PVFVP) was analyzed in 53 subjects (aged 25 to 77 years, mean 47) without cardiovascular disease who underwent transthoracic pulsed Doppler echocardiography. The forward flow velocity pattern was biphasic in 37 of the 53 subjects, with each of the 2 peaks in systole and diastole; flow was triphasic with 2 peaks in systole and the other peak in diastole in the remaining 16 subjects. Peak systolic and diastolic flow velocity ranged from 28 to 84 cm/s and from 27 to 71 cm/s, respectively. Mean systolic flow velocity was significantly greater than mean diastolic flow velocity (53 ± 12 vs 47 ± 11 cm/s, p < 0.01). Systolic flow velocity and the ratio of systolic to diastolic flow velocity increased and diastolic flow velocity decreased with aging (r = 0.52, p < 0.001, r = 0.70, p < 0.001 and r = −0.49, p < 0.001, respectively). Reverse flow occurred during the atrial contraction phase and its velocity (mean 20 cm/s) increased with aging (r = 0.56, p < 0.001). The parameters of PVFVP were compared with the ratio of peak early diastolic filling velocity to peak filling velocity at atrial contraction ( E A ratio) measured in the transmitral flow velocity pattern. As E A ratio increased, systolic flow velocity and systolic/ diastolic flow ratio and peak reverse flow velocity decreased (r = −0.40, p < 0.01, r = −0.67, p < 0.001 and r = −0.68, p < 0.001, respectively) and diastolic flow velocity increased (r = 0.58, p < 0.001). Thus, PVFVP can be assessed in adults by using transthoracic pulsed Doppler echocardiography. PVFVP is significantly affected by aging, at least partially reflecting altered left ventricular diastolic function with aging. These results can be used for comparison with patterns found in disease states.

Femoral artery flow velocities: A sensitive index of limb hemodynamics associated with venous occlusion

The peripheral hemodynamics associated with acute major peripheral vein occlusion in the canine were monitored noninvasively with a bidirectional Doppler ultrasound velocity flowmeter. Ligation of the femoral vein (FV), common iliac vein (CIV), or inferior vena cava (IVC) resulted in a significant reduction in mean femoral artery flow and were associated with a concomitant increase in mean femoral bed vascular resistance ( FBVR) . Occlusion of any of the veins attenuated proximal or forward femoral artery flow velocities ( V f) and augmented distal or reverse femoral artery flow velocities ( V r). The ratio of the peak reverse flow velocity to peak forward flow velocity (peak V r/ V f) was elevated with CIV and IVC occlusion. Slight but nonsignificant increases in peak V r/ V f occurred after FV occlusion. The percentage change in the ratio of the peak reverse femoral artery flow velocity to peak forward femoral artery flow velocity (%Δ V r/ V f) correlated in a positive linear fashion the percentage change in FBVR following ligation of the FV, CIV, or IVC ( r = 0.81, P < 0.001). These data suggest that femoral artery flow velocities as determined by a Doppler ultrasonic flowmeter may be a useful index of the peripheral hemodynamic status associated with peripheral venous occlusion.