Pulsed Tissue Doppler Imaging Research Articles

Tissue Doppler imaging in systemic sclerosis: A 3-year longitudinal study

ObjectivesTo investigate by standard echocardiography and pulsed-tissue Doppler imaging (TDI) the course of systemic sclerosis (SSc) heart disease and its correlation with epidemiological, clinical, and serological features of the disease and drug treatment. MethodsA total of 74 consecutive patients (69 females, between the ages of 19 and 71 years, and disease duration 1–43 years) and 71 controls underwent cardiac assessment at baseline and at 3-year follow-up. ResultsAt baseline, compared to controls, patients showed post-Bonferroni correction, impaired left (LV) and right ventricular (RV) diastolic function (Em/Am 0.85 ± 0.4 vs 1.5 ± 0.7, p = 0.0003; Et/At 0.9 ± 0.3 vs 1.3 ± 0.4, p = 0.0003), subtle LV and RV systolic dysfunction (Sm 13.7 ± 2.7 vs 15.4 ± 3.2cm/s, p = 0.031; St < 11.5cm/s in 16/74 patients vs 0 controls, p = 0.0031), and higher pulmonary artery systolic pressure (sPAP) (26.1 ± 6.0 vs 24.1 ± 5.1, p = 0.040). At 3-year follow-up, SSc patients showed a further deterioration of biventricular diastolic and systolic function and a further sPAP increase. At multiple regression analysis of baseline data, Em/Am < 1 was detected in 55/74 patients vs 25/71 controls (p < 0.0001) and was associated with age (p = 0.030); Et/At < 1 was detected in 16/74 patients vs 7/71 controls (p < 0.0001), was associated with NYHA class ≥ II (p = 0.033), late capillaroscopic pattern (p = 0.029), and a baseline cardiac Medsger severity score ≥ 1 (p = 0.029). TDI evidence of new abnormalities in RV and/or LV diastolic function was associated with a baseline cardiac Medsger severity score ≥ 1 (p = 0.01). Neither diastolic or systolic abnormalities nor sPAP changes correlated with treatment. ConclusionsOur study confirms that SSc patients exhibit biventricular systolic and diastolic dysfunction and increased sPAP and reveals further deterioration at 3-year follow-up.

Positive end-expiratory pressure aggravates left ventricular diastolic relaxation further in patients with pre-existing relaxation abnormality

BackgroundPositive end-expiratory pressure (PEEP) has been known to adversely influence cardiac output. Even though left ventricular (LV) diastolic function significantly contributes to LV performance, the effects of PEEP on LV diastolic function remains controversial. We, therefore, aimed to examine the effects of PEEP on LV diastolic function by use of pulsed wave Doppler tissue imaging in patients with pre-existing LV relaxation abnormality. MethodsSeventeen patients with peak early diastolic velocity of lateral mitral annulus (E′) <8.5 cm s−1 among patients who underwent coronary artery bypass graft surgery were evaluated. Echocardiographic and haemodynamic variables were measured with 0, 5, and 10 cmH2O of PEEP. E′ and deceleration time (DT) of peak early transmitral filling velocity (E) were used as echocardiographic indicators of LV diastolic function. ResultsMean arterial blood pressure decreased during 10 cmH2O PEEP, compared with that during 0 cmH2O PEEP. E′ showed a gradual and significant decrease with an incremental increase in PEEP (6.9±0.9, 5.8±0.9, and 5.2±1.2 cm s−1 during 0, 5, and 10 cmH2O PEEP, respectively), and DT of E was prolonged during 10 cmH2O PEEP, compared with that during 0 cmH2O PEEP. ConclusionsIncreasing PEEP led to a progressive decline in LV relaxation in patients with pre-existing LV relaxation abnormality.

High intensity, interval exercise improves diastolic function and ergometric capacity of patients with chronic heart failure: a phase III randomized clinical trial

Background: The aim of this work was to evaluate the effect of high intensity, interval exercise on echocardiographic markers of systolic and diastolic ventricular function among chronic heart failure (CHF) patients. Methods: A phase III clinical trial. Of the 100 consecutive CHF patients (NYHA class II-IV, ejection fraction<30%) that were randomly allocated to exercise treatment (n=50) or control (n=50), 72 (exercise group, n=33, 63±9 years, 88% men, 70% ischemic heart failure and exercise group, n=39, 56±11 years, 82% men, 70% ischemic heart failure) completed the study. Particularly, the intervention group followed a high intensity, interval ergometric aerobic training (i.e., 30 sec at 100% of max workload, 30 sec at rest) for 30 min/day-by-12 weeks, whereas the control group received regular instructions. Echocardiographic assessment was performed in all patients before and after the intervention. The pulsed tissue Doppler imaging (TDI) of mitral annulus was characterized by the systolic wave Smv, and the diastolic waves: Emv and Amv. Furthermore the ratio E/Emv and the flow propagation velocity, left ventricular outflow velocity integral (VTI), and left atrial fraction were calculated; where E is the rapid mitral filling wave. The bioethics committee approved the protocol. Results: Both groups reported similar physical activity status at baseline, as assessed through the IPAQ (p=0.60), had similar body mass index (p=0.08), smoking habits (p=0.17), hypertension (p=0.15), diabetes (p=0.46) and dyslipidemia (p=0.83). General mixed effects models revealed that intervention group increased VTI by 4% (p=0.05) as compared with the control group in which no significant change was observed (p=0.47).Furthermore, the intervention group decreased Emv/Vp by 14% reduction (p=0.06), decreased E to A ratio by 24% (p=0.004) and decreased by 8% E to Emv ratio (p=0.05), with no significant change on control group (all p>0.05). Additionally, intervention group improved 6-minutes-walk test by 13% as compared with intervention group (p=0.10), the VO2 max level by 12.5% ml/kg/min (p=0.002), the VCO2 level by 21% L/min (p=0.01), and total power by 83% watts (p=0.04), as compared with the intervention group. No significant differences were detected in both groups according to left ventricular ejection fraction, but a modest reduction of pulmonary artery systolic pressure, left atrial fraction in the intervention group. Conclusion: High intensity, systematic aerobic training seems to improve left ventricular diastolic function in parallel with an improvement in ergometric capacity and tissue oxygen delivery.

Right Ventricular and Septal Function in Patients with Pulmonary Hypertension

Pulmonary hypertension (PHT) exacerbates the functions of both ventricles. This prospective, randomised study was planned to investigate the effects of PHT on kinetics of both ventricles and the septum. Twenty-five patients were randomly selected among the patients who had been planned to undergo mitral valve replacement (MVR) because of isolated mitral stenosis and divided into two groups according to their preoperative pulmonary artery pressure (PAP) values. Blood pool gated single photon emission tomography (BPGS) and transthoracic echocardiography were performed. Ventricles' regional, global and functional parameters were also assessed by using pulsed wave Doppler tissue imaging (DTI). Preoperative and postoperative PAP of the group 1 (PAP < 50 mmHg) were 40.0 ± 2.8 and 30.0 ± 2.6 mmHg (p = 0.03), group 2 (PAP ≥ 50 mmHg) were 71.9 ± 4.7 and 50.6 ± 3.5 mmHg (p < 0.05). The global right and left ventricle scores were decreased after the operation. The decrement was only significant in group 2. Considering the septal kinetics, right ventricle septal score was decreased from 7.6 to 3.3 (p < 0.05) in group 1, from 3.8 to 1.6 (p < 0.05) in group 2 postoperatively. Following MVR, a decrement in PAP values, and an improvement in ventricular function, especially in the right ventricular and septal kinetics were achieved. Furthermore, it was found that both DTI and BPGS techniques are beneficial to investigate the functional changes postoperatively and in the follow-up period of the patients who undergo mitral valve surgery.

Usefulness of Pulsed Wave Tissue Doppler Imaging in Assessment of Left Ventricular Functions in Children with Beta-Thalassemia Major

To evaluate the changes in the LV systolic and diastolic function in children with beta-thalassemia major (β-TM) using pulsed wave tissue doppler (TD) echocardiography. Clinical, conventional echo doppler and pulsed wave tissue doppler imaging parameters were compared in 40 beta-thalassemia major patients (mean age, 6.52 ± 3.5 y) and 25 age and sex matched normal subjects (mean age, 6.5 ± 2.7 y). There were no significant statistical differences between mean fractional shortening (FS) and ejection fraction (EF) of left ventricle (LV) of the patients and control group. Children with beta-thalassemia had significantly lower E' wave velocities measured at the left ventricular septal annulus (8.1 ± 3.3 vs. 13 ± 2.5, P < 0.001), lateral margin of the mitral annulus (9.1 ± 5.4 vs. 13.3 ± 2.5, P < 0.001) and lateral margin of the tricuspid annulus (9.3 ± 3.9 vs. 13.3 ± 2.5, P < 0.001) when compared to the control group. Furthermore children with beta-thalassemia had significantly lower E'/A' wave ratio at the left ventricular septal annulus (0.76 ± 0.34 vs. 1.36 ± 0.23), lateral margin of the mitral annulus (0.83 ± 0.17 vs. 1.28 ± 0.22), and lateral margin of the tricuspid annulus ((0.90 ± 0.27 vs. 1.26 ± 0.23, (P < 0.05) when compared to the control group. This study showed that patients with beta-thalassemia major and normal conventional echo doppler parameters had statistically significant changes detected by pulsed wave tissue doppler imaging.

Echocardiographic features of congestive heart failure in patients with chronic obstructive pulmonary disease

Aim. To optimize echocardiographic diagnosis of congestive heart failure in patients with chronic obstructive pulmonary disease (COPD). Methods. Several modes of echocardiography using HD 11XE (Philips, USA) ultrasound scanner, 24-hour ECG monitoring using Microvit MT-101 (Schiller, Switzerland) 3-channel recorder and spirometry using АFD-02-«МFP» (Russia) machine were performed in 157 patients aged 39-76 years (male - 114, female - 43) who were divided into the following subgroups: (1) patients with COPD alone, (2) patients with COPD and concomitant arterial hypertension, (3) patients with COPD and concomitant ischemic heart disease, (4) patients with ischemic heart disease, (5) healthy controls. Results. 55.4% of patients with COPD had clinical signs of congestive heart failure (with signs of isolated diastolic dysfunction in 85.7% of patients with congestive heart failure). Diastolic dysfunction was associated with increase of peak isovolumic velocity (IVV) and even more significant decrease of peak early (Ea) and late (Aa) diastolic annular tricuspid vale velocities ratio at pulsed Doppler tissue imaging compared to patients without congestive heart failure. In patients with isolated COPD and isolated diastolic dysfunction echo signs of right ventricle dilatation, and in patients with COPD and concomitant ischemic heart disease - also of pulmonary artery trunk dilatation and hypertrophy of both ventricles were significantly more frequent. Systolic dysfunction was found only in patients with COPD and concomitant ischemic heart disease, causing longitudinal systolic dysfunction of the right ventricle seen as a reduction of systolic excursion and peak systolic (Sa) annular velocity, increased Myocardial Performance Index (Tei Index) and corrected isovolumic relaxation time, as well as hypertrophy of both ventricles and left ventricular dilatation. Conclusion. Echocardiography (Doppler tissue imaging) can be used for congestive heart failure diagnosis verification in patients with COPD.

Acute effects of cigarette smoking on the cardiac diastolic functions

BackgroundSmoking is an independent risk factor for coronary heart diseases and it increases all causes of cardiovascular morbidity and mortality. Aim of the workTo assess the acute effect of cigarette smoking on ventricular diastolic functions (LV and RV) in healthy, young, and slim smokers. MethodsThirty volunteers who had recently commenced smoking (less than one year) and who smoked 1–2 cigarettes per day, underwent ECG, 2D and M-mode echocardiography, standard Doppler echocardiography, pulsed TDI (tissue Doppler imaging) on septal and lateral side of mitral annulus and lateral tricuspid annulus. Vp values were measured. The investigator asked them to hold smoking for at least two days after which echocardiographic examination was conducted before smoking one cigarette and the second examination conducted immediately after smoking one cigarette containing at least 0.4mg of nicotine. ResultsDoppler findings over the mitral valve showed the E wave was significantly reduced from 82.7±10.4 to 74.6±10.4 after smoking; the A wave increased; the E/A ratio was reduced from 1.5±0.3 to 1.2±0.2; the E′ septal significantly decreased (15.3±2.4 vs. 11.2±1.1) after smoking, and the E/E′ ratio increased from 5.5±1.1 to 6.7±1.1. Doppler findings over the tricuspid valve showed the E wave was reduced from 60.6±9.7 to 52.7±9.6; the A wave increased from 42.2±6.5 to 50.1±6.6; and the E/A ratio decreased (1.45±0.25 vs. 1.06±0.19). The E′ significantly decreased from 14.1±1.8 to 10.9±2.4, while the A′ increased (10.2±2.4 vs. 12.7±3.6) after smoking; and the IVRT of the RV was significantly prolonged from 62.9±7.5 to 68.7±7.9 after smoking. The Vp was markedly reduced from 67.8±8 to 55.2±3.5 after smoking. These findings reflected on the LV filling pressure (LVFvp) which increased from 9.8±1.4 to 10.5±1.3 after smoking. All changes were statistically significant at P<0.001. ConclusionsOur study reveals that cigarette smoking can result in significant acute alteration in the diastolic functions of both ventricles.

Assessment of myocardial viability using early systolic mitral annular motion velocities responses to dobutamine infusion in patients with previous myocardial infarction

Dobutamine stress echocardiography (DSE) is widely used for detection of myocardial viability. The main limitation of DSE is its subjective interpretation. Assessment of mitral annular motion velocities with tissue Doppler imaging is simple and quantitative measurement. It is to determine the relationship between myocardial viability and regional systolic mitral annular motion velocity response to dobutamine stress in patients with previous myocardial infarction with pulsed tissue Doppler imaging (TDI). Our study group included 101 patients with previous myocardial infarction. All the patients underwent conventional DSE and dobutamine stress tissue Doppler echocardiography (DSTDE) measuring velocities of presystolic wave (SW1) and peak systolic wave (SW2) at rest and during low-dose dobutamine infusion. After exclusion of the normokinetic walls, we analyzed 505 walls.(Table 1) Using the conventional DSE as the gold standard for detection of myocardial viability, the sensitivity of the DSTDE using SW1 for detection of viability was 94.8% and its specificity was 91.7%, while the sensitivity using SW2 for detection of viability was 87.8%, and its specificity was 81.5%. The presystolic wave during DSTDE showed a greater sensitivity and specificity for the prediction of myocardial viability than the systolic wave.

Evaluation of myocardial function using tissue Doppler imaging in children with moderate scorpion envenomation

Context. Scorpion envenomation is an important public health problem. It can cause life-threatening complications such as respiratory, neurological and cardiovascular compromise. Systemic envenoming signs and mortality rates are dramatically higher in children. Objective. The objective of this study was to evaluate myocardial function using pulsed tissue Doppler imaging in patients with moderate scorpion envenomation. Materials and methods. The study was conducted from July to October 2009 in the South-East Anatolia region of Turkey. The study population consisted of 30 children with moderate scorpion envenomation and 30 age- and sex-matched normal controls. Severe and mild envenomations were excluded. In addition to echocardiographic examination, pulsed tissue Doppler imaging was performed. Results. The average age was 7.6 ± 4.3 years in patients and 7.9 ± 3.2 years in controls (p value, 0.77). The mean heart rate was 114 ± 19 beats/min (range, 72–164) in patients and 95 ± 14 beats/min (range, 72–127) in controls (p < 0.01). Sinus tachycardia (> 120 beats/min in children) was detected in ten (33.3%) patients. Myocardial performance index (MPI) was obtained with tissue Doppler imaging. The ejection fraction, the fractional shortening, the MPI of the left ventricle, the MPI of the right ventricle, the left ventricular isovolumetric contraction time (ICT), the left ventricular isovolumetric relaxation time (IRT), the left ventricular ejection time, the right ventricular ICT, the right ventricular IRT and the right ventricular ejection were not statistically different between the patients and the controls (p > 0.05). Discussion. We did not detect any considerable myocardial involvement in the children presenting with moderate scorpion envenomation except for sinus tachycardia. If the patients are treated with antivenom within 4 h, patients with moderate scorpion envenomation may not develop cardiac dysfunction.

125: Haemodialysis: effects of acute decrease in preload on echocardiographic indices of systolic and diastolic function of the left ventricle in chronically uremic patients

Conventional echocardiographic (ECHO) parameters of left ventricular (LV) systolic and diastolic function have been shown to be load-dependent; however, the impact of preload reduction on tissue Doppler (TD) parameters of LV function is incompletely understood. The aim of this study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis patients. Eighty-one chronically uremic patients (40 males; aged 52,43±16,35 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared. Fluid volume removed by HD was 1640 ±730 cm3. Hemodialysis led to reduction in LV end-diastolic volume (p<0,001), end-systolic volume (p<0,001), left atrium area (p<0,001), peak early (E wave) transmitral flow velocity (p <0,001), the ratio of early to late Doppler velocities of diastolic mitral inflow (p <0,001) and aortic time velocity integral (p<0.001). No significant change in peak S velocity of pulmonary vein flow after HD. Early and late diastolic (Ea) TDI velocities and the ratio of early to late TDI diastolic velocities (Ea/Aa) on the lateral side of the mitral annulus decreased significantly after HD (p=0,013; p=0,007 and p=0,008; respectively). Velocity of flow progression (Vp) during diastole was not affected by preload reduction. Pulmonary artery systolic pressure and the diameter of the inferior vena cava decreased significantly (p <0,001and p <0,001; respectively) after HD. Most of Doppler-derived indices of diastolic function are preload-dependant. Velocity of flow progression was not or minimally affected by preload reduction in hemodialysis patients.

Pulsed tissue Doppler imaging of the left ventricular septal mitral annulus in healthy dogs

This study evaluated pulsed TDI variables including the isovolumic time interval and duration of the major wave in a population of large healthy dogs. Longitudinal myocardial motion at the septal mitral annulus was evaluated with pulsed TDI in 45 healthy adult dogs. Maximal myocardial velocities, isovolumic time intervals, and duration of the myocardial waves were measured. The correlation between time intervals and velocity variables was also investigated. The mean maximal systolic velocity was 6.92 ± 1.78 cm/sec, the mean early diastolic velocity (Em) was 6.58 ± 1.81 cm/sec, the mean late diastolic velocity (Am) was 5.10 ± 2.00 cm/sec, the mean isovolumic contraction time (IVCT) was 53.61 ± 95.13 msec, and the mean isovolumic relaxation time (IVRT) was 26.74 ± 57.24 msec. The early diastolic mitral inflow velocity (E)/Em ratio was 10.94 ± 3.27 while the Em/Am ratio was 1.40 ± 0.40. There was a negative correlation between Am duration and Am amplitude, and a positive correlation between the IVRT and Em/Am ratio (p < 0.05). The normal LV parameter using pulsed TDI method could be used as the reference range for identifying myocardial dysfunction in dogs.

Association of left ventricular motion and central augmentation index in healthy young men

Central blood pressure is a determinant of cardiovascular outcome; however, it can be described by parameters other than systolic and diastolic pressure with central augmentation index (AIx) often utilized. Although generally considered as determined by peripheral pressure wave reflection, not all data are consistent with this interpretation of AIx. We hypothesized that the motion of the heart during systole may influence central pressure waveform morphology, including the AIx. We studied the carotid pressure waveform, aortic stiffness and endothelial function in 20 healthy young men (full data available in 19). Arterial stiffness was measured by carotid femoral pulse wave velocity (cfPWV), endothelial function by peripheral arterial plethysmography (PAPl) and central blood pressure waveform by carotid applanation tonometry. Basal cardiac motion was assessed with pulsed wave tissue Doppler imaging of the septal mitral annulus. Carotid AIx decreased after the administration of glyceryl trinitrate by 11.3 ± (sem) 4.6% (P = 0.02); however, time to the inflection point (Ti) did not change. During systolic contraction at both baseline and after glyceryl trinitrate, time to peak annular systolic velocity was directly related to, and always preceded, carotid Ti (R(2) = 0.81; P < 0.01). Carotid Ti and AIx were not related to cfPWV or endothelial function. In fit young men, rather than only being a consequence of arterial properties Ti, and therefore central AIx, may be substantially determined by left ventricular systolic function. These findings question the interpretation of central AIx as a measure of pressure wave reflection and aortic stiffness and potentially impact its interpretation in diagnosis and treatment of cardiovascular risk.

Mitral annular systolic velocity as a marker of preclinical systolic dysfunction among patients with arterial hypertension

BackgroundThe aim of this study was to investigate early changes in left ventricular longitudinal systolic function in patients with hypertension (HTN) with and without concomitant diastolic dysfunction (DD) and the clinical implications of these findings.MethodWe enrolled 299 patients with HTN and 297 age-matched patients with HTN and DD and compared both groups with an age-matched control group consisting of 100 healthy subjects. The long axis systolic function was investigated by determining the average peak systolic velocity of the septal and lateral mitral sites (Smavg) using spectral pulsed wave tissue Doppler imaging (TDI).ResultsWe found a strong negative trend toward the reduction of velocity, which is dependent on the grade of HTN, on the magnitude of DD, and also on the gender and age of the subjects (r=−0.891/-0.580; p<0.0001). The data showed that the beginning and evolution of HTN are related to a slight but significant reduction in the long axis systolic function (10.2-10.0 cm/s; p<0.0001), and DD worsens this initial finding (9.8-8.8 cm/s; p<0.0001).ConclusionThe strength of the study is the analysis of incremental changes in longitudinal contraction in patients with different stage of HTN but not so many the classification of the degree of systolic dysfunction. The importance of our results lies in the fact that these initial changes in systolic contraction could be used as an early sign that should prompt optimization of the treatment of HTN.

1139 Right Heart Dimensions and Function at 6 Years-Of-Age Using 2D- and 3D-Echocardiography

Background and AimSurvival after premature birth and neonatal lung disease is nowadays almost universal. To determine the long-term health outcomes for these infants, cardio-respiratory follow-up is needed. Whereas normative reference...

Assessment of left ventricular geometry, functions and mass in patients with metabolic syndrome

Background and aims The frequent coexistence of obesity, arterial hypertension, and lipid and carbohydrate disorders is well known. Although these conditions have been identified as independent risk factors for impaired left ventricular diastolic function, there is a paucity of data on the dysfunction among patients with metabolic syndrome (MS). The aim of this study was to determine the impact of metabolic syndrome on left ventricular systolic and diastolic functions, mass and geometry by using conventional echocardiography and pulsed wave tissue Doppler imaging in individuals with MS compared to healthy subjects. Methods The study included 120 subjects divided by half into control and case group: 60 subjects (30 males and 20 females) with MS (diagnosed according to consensus statement from the International Diabetes Federation (platinum standard)) aged 54.4 ± 9.5 years and 60 healthy subjects (32 males and 28 females) aged 50.3 ± 13.7 years. Left ventricular ejection fraction (LVEF) was measured with the Tiech method in the short axis parasternal view by averaging measurements from five consecutive cardiac cycles. The LV diastolic function was estimated with Doppler measurement of transmitral blood flow and determination of the maximal rates for E and A peaks, E/A ratio, delay time (DT) for early diastolic filling rate, E′, A′ and E′/A′ ratio according to criteria of the European Study Group on diastolic heart failure. IMP was be calculated as the sum of IVRT and IVCT divided by ventricular ET (IMP = IVRT + IVCT/ET). LV mass was determined using the corrected cube formula as (0.80 × {1.04 × [(septal thickness + LV internal diameter + posterior wall thickness) 3 − (LV internal diameter) 3 ]} + 0.6). Results The assessed parameters using conventional and tissue Doppler echocardiography showing that those with metabolic syndrome had greater LV mass and significantly lower E/A ratio; increased LVH and significantly higher IMP, indicating impaired global left ventricular functions in patients with MS compared with control subjects without MS. There were no statistically significant difference in EF percentage. Conclusions Our results demonstrate that LV functions are impaired in patients with metabolic syndrome using IMP and E/A ratio. LVH incidence are higher in metabolic syndrome patients. To conclude metabolic syndrome are associated with significant cardiac functions deterioration and should be prevented and treated in proper manner.

Fetal tissue Doppler imaging in pregnancies complicated with preeclampsia with or without intrauterine growth restriction

This study's aim was to evaluate the effect of preeclampsia and intrauterine growth restriction (IUGR) on fetal cardiac function, and the relationship of the latter with adverse pregnancy outcomes. We did a cross-sectional study of 132 women with uncomplicated singleton pregnancies, 34 with preeclampsia without IUGR, and 12 with preeclampsia and IUGR. Fetal cardiac structure and function were evaluated using fetal two-dimension ultrasound, pulsed wave Doppler and tissue Doppler imaging (TDI). Data were analyzed by t-tests, ANOVA, Chi-square tests, or Wilcoxon rank-sum test. Compared with the normal pregnancy group, mitral/tricuspid early systolic peak velocity of annulus/late diastolic peak velocity of annulus (Sa) and left ventricular (LV)/right ventricular (RV) early diastolic peak velocity at the annulus (Ea) in TDI decreased in preeclampsia with or without IUGR (P < 0.05). LV/RV Ea underwent a gestational decrease in preeclampsia with or without IUGR (P < 0.05). The changes in mitral/tricuspid Sa and LV Sa associated with preeclampsia were even more pronounced with preterm delivery at less than 34 gestational weeks and stillbirth (P < 0.05). Intrauterine growth restriction influences fetal cardiac function in the presence of preeclampsia, and TDI may be a sensitive and preferable method to detect such changes. Fetal LV/RV Ea is a potential marker for early fetal cardiac diastolic impairment, and mitral/tricuspid Sa and LV Sa may be predictors for adverse pregnancy outcomes.

The role of echocardiography in the assessment of right ventricular systolic function in patients with transposition of the great arteries and atrial redirection

Although dysfunction of the systemic right ventricle (RV) in patients with complete transposition of the great arteries (TGA) after atrial redirection by Mustard or Senning procedures is well recognized, there are few data on systemic RV geometry and function. Echocardiography is a widely available imaging technique that is particularly suitable for clinical follow-up because of its non-invasive nature, low cost and lack of ionizing radiation. To examine the feasibility and variability of transthoracic echocardiography variables in the assessment of the systemic RV. Multivariable transthoracic echocardiographic analysis, including assessment of global function variables (RV ejection fraction [RVEF; Simpson's method], RV fractional shortening [RVFS] and dP/dt), longitudinal function variables (tricuspid annular plane systolic excursion [TAPSE], peak systolic velocity at the junction of the RV free wall and the tricuspid annulus, assessed with pulsed tissue Doppler imaging [S' TDI]), tricuspid regurgitation and asynchrony, was performed in 35 consecutive patients with TGA after atrial redirection. Functional variables were compared with magnetic resonance imaging (MRI). Inter- and intraobserver echocardiographic analysis variability was assessed in ten randomly selected cases. Global and longitudinal function variables were not correlated with RVEF calculated by MRI, except for S' TDI, which was weakly correlated (P = 0.02, r = 0.37). Asynchrony assessment was feasible in all patients. Inter- and intraobserver echocardiographic analysis variability was high for RVEF, RVFS and dP/dt (> 10%), and low for TAPSE and S' TDI (5%). Owing to geometric changes, presumed contractility pattern shift and retrosternal position, conventional echocardiographic variables are not relevant for RV function assessment. Assessment of asynchrony and tricuspid regurgitation is easily feasible in routine practice and highly reproducible. Echocardiography does not permit complete assessment of the systemic RV after atrial redirection but is fully complementary with MRI and should not be abandoned. Future improvements in transducers and dedicated software should permit major improvements in the near future.

The Impact of Preload Alteration on the Myocardial Performance Index through Implementing Positive End Expiratory Pressure

Load independent methods should be used for the assessment of ventricular function. Debate still exists regarding whether tissue Doppler imaging (TDI) indices are influenced by preload. Here, we evaluated the effect of positive end expiratory pressure (PEEP) related preload reduction on both conventional pulsed Doppler (PD) and TDI myocardial performance index (MPI). Thirty-eight mechanically ventilated patients of 3 months to 12 years old (mean ± SD age of 30 ± 11 months) without overt heart disease were enrolled. Doppler mitral inflow velocities, isovolumetric contraction and relaxation times and aortic ejection time in addition to TDI peak systolic, early and late diastolic velocities from the basal segment of left ventricular lateral wall were determined for each patient before and after applying high PEEP (10 cmH(2) O).PD-MPI was load dependent (0.61 ± 0.22 vs. 0.78 ± 0.25, P = 0.002). However, TDI-MPI did not significantly change after the use of high PEEP declining the left ventricular volume loading (0.78 ± 0.21 vs. 0.84 ± 0.22, P = 0.23). Hence, regarding various interfering pathophysiologic factors particularly preload reduction, it seems that TDI-MPI would be a more reliable index for the assessment of ventricular function.

Ventricular Function in Patients with End‐Stage Renal Disease Starting Dialysis Therapy: A Tissue Doppler Imaging Study

Heart failure is prevalent in end-stage renal disease (ESRD) patients on long-term dialysis. Detection of right ventricular (RV) dysfunction before starting dialysis may help to identify patients at a higher risk of developing heart failure. To assess RV function in predialysis patients using tissue Doppler imaging (TDI) derived myocardial performance index of RV (MPI-RV). Echocardiography including pulsed TDI of lateral tricuspid annulus was performed in 41 patients with ESRD before starting dialysis therapy and 12 age and gender matched healthy controls. RV dysfunction was defined as MPI > 0.4; a value above the median MPI in controls. Compared to controls, ESRD patients had significantly higher blood pressure and lower hemoglobin level. MPI-RV was significantly impaired in ESRD patients compared to control (0.6 vs. 0.4, P < 0.001). RV dysfunction was identified in 23 ESRD patients (56%). ESRD patients had significantly lower e' velocity and e'/a' ratio as compared with controls. Pulmonary hypertension was detected in 15 (36.5%) patients. Among ESRD patients, no correlation was detected between MPI-RV and calculated mean pulmonary artery pressure (r = -0.13, P = 0.47), pulmonary artery systolic pressure (r =-0.12, P = 0.6), left ventricular ejection fraction (r = 0.294, P = 0.06), or MPI of left ventricle (r = 0.3, P = 0.065). ESRD patients with and without pulmonary hypertension had similar MPI-RV (0.6 vs.0.62, P = 0.32). Subclinical RV dysfunction-as estimated by TDI derived MPI-is highly prevalent among ESRD patients even before starting dialysis therapy. Pulmonary hypertension is not significantly associated with RV dysfunction in these patients.

Cardiac resynchronization therapy in clinical responders: right ventricular echocardiographic changes at mid-term follow-up

Objective The objective of this study was to assess the mid-term eff ects of cardiac resynchronization therapy on systolic function and remodelling of the right ventricle in clinical responders and non-responders.Methods A biventricular system was implanted between July 2005 and May 2008 in 58 patients with heart failure NYHA class II-IV. At baseline, three and 15 months after implantation, the following parameters were determined: NYHA class, quality of life, six-minute walk test, echocardiography including assessment of right ventricular systolic function by tricuspid annular plane systolic excursion and by pulsed tissue Doppler imaging (myocardial peak systolic velocity was measured at the tricuspid annulus). We also assessed the presence of ventricular dyssynchrony.Results There were no signifi cant changes after three months of cardiac resynchronization therapy on right ventricular systolic function and remodelling in responders and non-responders. Among responders, we found a statistically signifi cant improvement of right ventricular systolic function and also a signifi cant decrease in the size of the right ventricle after 15 months of therapy (systolic excursion before therapy 17.8 ± 4.0 mm vs 19.4 ± 3.7 mm, P< 0.05, after therapy; peak systolic velocity initially 11.9 ± 2.9 cm/s vs 12.7 ± 3.2 cm/s; right ventricle size before therapy 29.3 ± 5.0 mm vs 27.8 ± 4.2 mm, P< 0.05, after therapy. These changes were not observed in non-responders.Conclusions Fifteen months after cardiac resynchronization therapy, we found a statistically signifi cant improvement of right ventricular systolic function and a signifi cant reduction of right ventricular size in responders to cardiac resynchronization therapy.