Reduction In Left Ventricular End-diastolic Volume Research Articles

Abstract 16619: Bone Marrow Cell Therapy Improves Left Ventricular Function And Survival in Patients With Chronic Ischemic Heart Disease and Cardiomyopathy

Introduction: Results from randomized controlled trials (RCTs) of bone marrow cell (BMC) therapy for cardiac repair have been discordant. The true impact of BMC therapy in patients with chronic ischemic heart disease (CIHD) and ischemic heart failure remain unclear. Hypothesis: We hypothesized that BMC injection would improve clinical outcomes and left ventricular (LV) parameters in patients with CIHD. Methods: We performed a systematic review and meta-analysis of data from RCTs of BMC therapy on LV ejection fraction (LVEF), LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV), infarct scar size, and clinical outcomes in patients with CIHD. Database searches based on specified criteria identified 15 eligible RCTs (enrolling 648 CIHD patients). Changes in predefined parameters were analyzed with random-effects meta-analysis. Peto odds ratio (OR) was calculated for clinical outcomes. Results: Compared with standard therapy, BMC transplantation improved LVEF (3.84%; 95% confidence interval [CI], 2.30 to 5.38; P<0.00001), reduced scar size (-5.90%; 95% CI, -8.03 to -3.78; P<0.00001) and LVESV (-10.37 ml; 95% CI, (-18.56 to -2.18; P=0.01). Reduction in LVEDV (-1.84 ml; 95% CI, -9.13 to 5.46; P=0.62) was not significant. The improvement in LVEF in BMC-treated patients was also significant (1.78%; 95% CI: 0.63 to 2.93; P=0.002) in a separate analysis of RCTs that used MRI. Importantly, BMC therapy reduced all-cause mortality (OR: 0.35; 95% CI 0.16 to 0.73; P=0.005) and incidence of cerebrovascular accident (CVA) (OR: 0.07; 95% CI, 0.01 to 0.55; P=0.01) and tended to reduce the incidence of heart failure (OR: 0.36; 95% CI 0.11 to 1.14; P=0.08) in patients with CIHD (Table). Conclusions: BMC therapy improves LVEF, LVESV, and infarct scar size in patients with CIHD. The improvement in LVEF was also confirmed in meta-analysis of RCTs using MRI. Importantly, these numerically small benefits translated into improved clinical outcomes in BMC-treated CIHD patients.

Left ventricular assist as a key factor for heart self-restoration in a 20-year-old patient with severe left ventricular dysfunction: five-year echocardiographic observation

A 20-year-old male patient was admitted to the hospital in a life-threatening condition, haemodynamically unstable, with symptoms of low output syndrome. An intra-aortic balloon pump was introduced together with inotropic support for more than two weeks without any clinical improvement. Left ventricular ejection fraction (LVEF) was 10–15%, left ventricular end-diastolic diameter (LVEDD) was 6.9 cm, and left ventricular end-diastolic volume (LVEDV) was 220 mL. Based on the above-mentioned symptoms and findings, acute, toxic, severely dilated cardiomyopathy was diagnosed. Despite maximum medical therapy no improvement was observed; therefore the patient was qualified for heart support using the Polish Cardiac Assist (POLCAS) system. On 01.08.2007 POLCAS was successfully implanted as a left ventricular (LV) support together with concomitant tricuspid valve annuloplasty. LV global and regional function was assessed twice weekly by transthoracic echocardiography. After four months of treatment LVEF was 25% and LVEDV was 150 mL, and the LV assist device was switch off. In ergospirometry the maximum oxygen consumption (VO2) was 22.8 mL/kg/min with a limit pulse of 157/min, and blood pressure 100/65 mmHg. The test repeated after 14 days showing that VO2max had improved to 25.9 mL/kg/min. After five months of LV support, due to significant improvement of the patient’s cardiac efficiency including myocardial contractility with increase of LVEF +35% and significant reduction of LVEDV 140 mL, LVEDD 5.5 cm, a decision to explant the Polish Ventricular Assist Device (POLVAD) was taken (Figs. 1, 2). Pharmacological treatment and rehabilitation were continued, and the patient’s cardiac competence was regained. The patient was discharged from the hospital in NYHA I class, with LVEF 40%. Six months later LVEF increased to 50%, and LVEDV and LVEDD were on the same level. During five years of observation, twice a year, LVEF, LVEDV, and LVEDD did not change.

The impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcomes.

A meta-analysis by Hoebers et al. reported that successful chronic total occlusion (CTO) recanalization resulted in an increase in left ventricular (LV) ejection fraction by 4.44% (P<0.01) and a reduction in LV end-diastolic volume by 6.14 mL/m(2) during follow-up as compared with baseline, suggesting beneficial LV remodeling. These findings are important as the myocardium supplied by a CTO frequently has sustained irreversible injury and further support the clinical benefits of CTO interventions.

Beneficial effects of elevating cardiac preload on left-ventricular diastolic function and volume during heat stress: implications toward tolerance during a hemorrhagic insult.

Volume loading normalizes tolerance to a simulated hemorrhagic challenge in heat-stressed individuals, relative to when these individuals are thermoneutral. The mechanism(s) by which this occurs is unknown. This project tested two unique hypotheses; that is, the elevation of central blood volume via volume loading while heat stressed would 1) increase indices of left ventricular diastolic function, and 2) preserve left ventricular end-diastolic volume (LVEDV) during a subsequent simulated hemorrhagic challenge induced by lower-body negative pressure (LBNP). Indices of left ventricular diastolic function were evaluated in nine subjects during the following conditions: thermoneutral, heat stress, and heat stress after acute volume loading sufficient to return ventricular filling pressures toward thermoneutral levels. LVEDV was also measured in these subjects during the aforementioned conditions prior to and during a simulated hemorrhagic challenge. Heat stress did not change indices of diastolic function. Subsequent volume infusion elevated indices of diastolic function, specifically early diastolic mitral annular tissue velocity (E') and early diastolic propagation velocity (E) relative to both thermoneutral and heat stress conditions (P < 0.05 for both). Heat stress reduced LVEDV (P < 0.05), while volume infusion returned LVEDV to thermoneutral levels. The reduction in LVEDV to LBNP was similar between thermoneutral and heat stress conditions, whereas the reduction after volume infusion was attenuated relative to both conditions (P < 0.05). Absolute LVEDV during LBNP after volume loading was appreciably greater relative to the same level of LBNP during heat stress alone. Thus, rapid volume infusion during heat stress increased indices of left ventricular diastolic function and attenuated the reduction in LVEDV during LBNP, both of which may serve as mechanisms by which volume loading improves tolerance to a combined hyperthermic and hemorrhagic challenge.

Interstitial Fibrosis, Left Ventricular Remodeling, and Myocardial Mechanical Behavior in a Population-Based Multiethnic Cohort

Background— Tagged cardiac magnetic resonance provides detailed information on regional myocardial function and mechanical behavior. T1 mapping by cardiac magnetic resonance allows noninvasive quantification of myocardial extracellular expansion (ECE), which has been related to interstitial fibrosis in previous clinical and subclinical studies. We assessed sex-associated differences in the relation of ECE to left ventricular (LV) remodeling and myocardial systolic and diastolic deformation in a large community-based multiethnic population. Methods and Results— Midventricular midwall peak circumferential shortening and early diastolic strain rate and LV torsion and torsional recoil rate were determined using cardiac magnetic resonance tagging. Midventricular short-axis T1 maps were acquired in the same examination pre- and postcontrast injection using Modified Look-Locker Inversion-Recovery sequence. Multivariable linear regression (estimated regression coefficient, B ) was used to adjust for risk factors and subclinical disease measures. Of 1230 participants, 114 had a visible myocardial scar by late gadolinium enhancement. Participants without a visible myocardial scar (n=1116) had no history of previous clinical events. In the latter group, multivariable linear regression demonstrated that lower postcontrast T1 times, reflecting greater ECE, were associated with lower circumferential shortening ( B =−0.1; P =0.0001), lower LV end-diastolic volume index ( B =0.6; P =0.0001), and lower LV end-diastolic mass index ( B =0.4; P =0.0001). In addition, lower postcontrast T1 times were associated with lower early diastolic strain rate ( B =0.01; P =0.03) in women only and lower LV torsion ( B =0.005; P =0.03) and lower LV ejection fraction (B=0.2, P =0.01) in men only. Conclusions— Greater ECE is associated with reduced LV end-diastolic volume index and LV end-diastolic mass index in a large multiethnic population without history of previous cardiovascular events. In addition, greater ECE is associated with reduced circumferential shortening, lower early diastolic strain rate, and a preserved ejection fraction in women, whereas in men, greater ECE is associated with greater LV dysfunction manifested as reduced circumferential shortening, reduced LV torsion, and reduced ejection fraction.

Acute hemodialysis effects on doppler echocardiographic indices.

Conventional echocardiographic (ECHO) parameters of systolic and diastolic function of the left ventricular (LV) have been shown to be load dependent. However, the impact of pre-load reduction on tissue Doppler (TD) parameters of LV function is incompletely understood. To evaluate the effect of a single hemodialysis (HD) session on LV systolic and diastolic function using pulsed Doppler echocardiography and pulsed tissue Doppler imaging (TDI), we studied 81 chronic HD patients (40 males; mean age 52.4 ± 16.4 years) with these tools. ECHO parameters were obtained 30 min before and 30 min after HD. Fluid volume removed by HD was 1640 ± 730 cm³. HD 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) trans-mitral 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 was noted. Early and late diastolic (E') TDI velocities and the ratio of early to late TDI diastolic velocities (E'/A') 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 pre-load reduction. Pulmonary artery systolic pressure and the diameter of the inferior vena cava decreased significantly (P <0.001 and P <0.001, respectively) after HD. We conclude that most of the Doppler-derived indices of diastolic function are pre-load-dependent and velocity of flow progression was minimally affected by pre-load reduction in HD patients.

Prognostic Importance of Pathophysiologic Markers in Patients With Heart Failure and Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome associated with multiple pathophysiologic abnormalities, including left ventricular (LV) diastolic dysfunction, longitudinal LV systolic dysfunction, abnormal ventricular-arterial coupling, pulmonary hypertension, and right ventricular (RV) remodeling/dysfunction. However, the relative prognostic significance of each of these pathophysiologic abnormalities in HFpEF is unknown. We prospectively studied 419 patients with HFpEF using echocardiography and sphygmomanometry to assess HFpEF pathophysiologic markers. Cox proportional hazards analyses were used to determine the associations between pathophysiologic markers and outcomes. Mean age was 65±12 years; 62% were women; 39% were black; comorbidities were common; and study participants met published criteria for HFpEF. RV abnormalities were frequent: 28% had abnormal tricuspid annular plane systolic excursion, 15% had reduced RV fractional area change, and 34% had RV hypertrophy. During a median follow-up time of 18 months, 102 (24%) were hospitalized for HF and 175 (42%) experienced the composite end point of cardiovascular hospitalization or death. Decreased LV compliance, measured as reduced LV end-diastolic volume at an idealized LV end-diastolic pressure of 20 mm Hg (EDV20), and RV remodeling, as indicated by increased RV wall thickness, were the 2 pathophysiologic markers most predictive of worse outcomes: adjusted hazard ratio per 1 SD decrease in EDV20=1.39 (95% confidence interval [CI], 1.10-1.75; P=0.006), and hazard ratio per 1 SD increase in RV wall thickness=1.37 (95% CI, 1.16-1.61; P<0.001). These associations persisted after additional adjustment for markers of HF severity. By contrast, markers of LV relaxation, longitudinal LV systolic dysfunction, and ventricular-arterial coupling were not significantly associated with adverse outcomes. In patients with HFpEF, reduced LV compliance and RV remodeling are the strongest pathophysiologic predictors of adverse outcomes.

Airflow obstruction and left ventricular filling pressure in suspected chronic obstructive pulmonary disease

Left ventricular (LV) filling impairment is present in patients with chronic obstructive pulmonary disease (COPD). Airflow obstruction is related to reduced LV end-diastolic volume, stroke volume, and cardiac output. The ratio of peak early diastolic filling velocity of the mitral inflow to peak early diastolic velocity of the mitral annulus (E/e′), an echocardiographic parameter, can be applied as a surrogate marker of LV filling pressures. Forty-seven individuals with suspected COPD underwent pulmonary function tests and echocardiography. The ratio of forced expiratory volume in 1s to forced vital capacity (FEV1/FVC) and the E/e′ ratio were determined. Multivariate linear regression analysis showed that the FEV1/FVC ratio (β=0.01; 95% confidence interval, 0.001–0.019; p=0.036) independently predicted the log transformed E/e′ ratio. An increase of FEV1/FVC ratio (in percentage) by 1 unit was associated with an increase of the E/e′ ratio multiplied by 1.01. Airflow obstruction inversely predicts LV filling pressure in suspected COPD cases.

Aortic Regurgitation and Left Ventricular Remodeling After Transcatheter Aortic Valve Implantation

Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) has been associated with poor outcomes, but little is known about how it evolves over time. We evaluated left ventricular (LV) function, remodeling, and the occurrence and evolution of AR after TAVI by using cardiac MRI. Forty-three patients treated with transfemoral TAVI underwent cardiac MRI 1 week and 6 months after TAVI. LV volumes and function were assessed by using standard cine MRI sequences. Phase-contrast imaging was performed to quantify the degree of AR. The mean age of the evaluated patients was 80 years, and 65% of patients were women. At baseline MRI, the median LV ejection fraction was 58.1%, which improved significantly at follow-up to 63.4% (P<0.0001). A significant reduction of LV end-diastolic volume (149.7 ± 41.4-140.1 ± 43.9 mL; P=0.014) and of LV mass (156.3 ± 32.8-142.7 ± 39.3 g; P<0.001) was observed. Over time, aortic regurgitant fraction increased slightly but significantly from 5.2% to 7.8% (P=0.04). Subgroup analysis revealed that significant changes of LV ejection fraction, volumes, and mass only occurred in patients with no or mild AR at baseline MRI, whereas those parameters remained unchanged in patients with AR more than or equal to grade II. By using cardiac MRI in patients with TAVI, a significant improvement of LV function, volume, and mass can be documented. Mild-to-moderate AR is commonly seen, and AR shows a small increase over time. More-than-mild AR seems to prevent LV functional and structural recovery after TAVI.

Percutaneous Mitral Valve Repair in the Initial EVEREST Cohort

Background— Percutaneous repair of mitral regurgitation (MR) permits examination of the effect of MR reduction without surgery and cardiopulmonary bypass on left ventricular (LV) dimensions and function. The goal of this analysis was to determine the extent of reverse remodeling at 12 months after successful percutaneous reduction of MR with the MitraClip device. Methods and Results— Of 64 patients with 3 and 4+ MR who achieved acute procedural success after treatment with the MitraClip device, 49 patients had moderate or less MR at 12-month follow-up. Their baseline and 12-month echocardiograms were compared between the group with and without LV dysfunction. In patients with persistent MR reduction and pre-existing LV dysfunction, there was a reduction in LV wall stress, reduced LV end-diastolic volume, LV end-systolic volume and increase in LV ejection fraction in contrast to those with normal baseline LV function, who showed reduction in LV end-diastolic volume, LV wall stress, no change in LV end-systolic volume, and a fall in LV ejection fraction. Conclusions— Patients with pre-existing LV dysfunction demonstrate reverse remodeling and improved LV ejection fraction after percutaneous mitral valve repair. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT00209339, NCT00209274.

Effect on Cardiac Function of Cardiac Resynchronization Therapy in Patients With Right Bundle Branch Block (from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy [MADIT-CRT] Trial)

Cardiac resynchronization therapy (CRT) is effective for the treatment of patients with heart failure and a wide QRS duration, particularly left bundle branch block. However, subjects with right bundle branch block (RBBB) do not appear to benefit from CRT. The aim of this study was to determine whether patients with specific RBBB conduction patterns responded to CRT in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) trial. In the present post hoc analysis, patients with RBBB who received CRT with an implantable cardioverter defibrillator (n = 132) were divided into 2 groups according to the baseline QRS morphology in the inferior and high lateral leads: group 1: left anterior fascicular block (LAFB) pattern (n = 80; 60.6%); and group 2: non-LAFB pattern (n = 52; 39.4%). Subjects with RBBB who received an implantable cardioverter defibrillator served as the control group (n = 87). The primary end point was echocardiographic response to CRT, defined as percent change in left ventricular (LV) and left atrial volumes from baseline to 1 year. The secondary end point was heart failure or death. The non-LAFB group demonstrated a significantly larger percent reduction in LV end-diastolic volume, LV end-systolic volume, and left atrial volume compared to controls (-11%, p <0.0001; -17%, p <0.0001; -15%, p <0.0001, respectively) and LAFB (-5%, p = 0.028; -7%, p = 0.019; -6%; p = 0.022; respectively) by multivariate analysis. No difference was found in the 3-year crude event rates for death or heart failure among the LAFB (22%), non-LAFB (21%), or ICD-only (20%) groups (p = NS). In conclusion, conduction patterns influence echocardiographic response to CRT in patients with RBBB, with favorable reductions in the LV and left atrial volumes in those without an LAFB conduction pattern. This echocardiographic benefit did not translate into a reduction in heart failure or death during a 3-year follow-up period.

The Influence of Left Ventricular Ejection Fraction on the Effectiveness of Cardiac Resynchronization Therapy

The aim of this study was to evaluate the relationship between left ventricular (LV) ejection fraction and clinical outcome to cardiac resynchronization therapy (CRT) in mild heart failure patients enrolled in MADIT-CRT [corrected]. Left ventricular ejection fraction (LVEF) is a surrogate marker of heart failure (HF) status and associated risk. Data on the effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) in patients with mild HF and better LVEF are limited. In the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) study, the echocardiography core laboratory assessed baseline LVEF independent of the enrolling centers and identified a range of LVEFs, including those >30% (i.e., beyond the eligibility criteria). Echocardiographic response with CRT, defined as percent change in left ventricular end-diastolic volume (LVEDV), was analyzed in 3 prespecified LVEF groups: >30%, 26% to 30%, and ≤25%. The primary endpoint was HF or death. Secondary endpoint included all-cause mortality. LVEF was evaluated in 1,809 study patients. There were 696 (38%) patients with LVEF >30% (in the range of 30.1% to 45.3%); 914 patients (50.5%) with LVEF 26% to 30%; and 199 patients with LVEF ≤25% (11%). The mean reduction in LVEDV with CRT-D therapy at the 1-year follow-up was directly related to increasing LVEF (LVEF >30%: 22.3%; LVEF 26% to 30%: 20.1%; and LVEF ≤25%: 18.7% reduction, respectively [p = 0.001]). CRT-D treatment similarly reduced the risk of HF/death in patients with LVEF >30% (hazard ratio [HR]: = 0.56 [95% confidence interval (CI): 0.39 to 0.82], p = 0.003), LVEF 26% to 30% (HR: 0.67: [95% CI: 0.50 to 0.90], p = 0.007), and LVEF ≤25% (HR: 0.57 [95% CI: 0.35 to 0.95], p = 0.03; all p values for LVEF-by-treatment interactions >0.1). In MADIT-CRT, the clinical benefit of CRT was evident regardless of baseline LVEF, including those with LVEF >30%, whereas the echocardiographic response was increased with increasing LVEF, indicating that CRT might benefit patients with better LVEF. (Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy [MADIT-CRT]; NCT00180271).

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.

Diastolic relaxation and compliance reserve during dynamic exercise in heart failure with preserved ejection fraction

BackgroundRecent studies have examined haemodynamic changes with stressors such as isometric handgrip and rapid atrial pacing in heart failure with preserved ejection fraction (HFpEF), but little is known regarding left...

Dependency of Cardiac Resynchronization Therapy on Myocardial Viability at the LV Lead Position

This study sought to analyze the effectiveness of cardiac resynchronization therapy (CRT) related to the viability in the segment of left ventricular (LV) lead position defined by myocardial deformation imaging. Echocardiographic myocardial deformation analysis allows determination of LV lead position as well as extent of myocardial viability. Myocardial deformation imaging based on tracking of acoustic markers within 2-dimensional echo images (GE Ultrasound, GE Healthcare, Horton, Norway) was performed in 65 heart failure patients (54 ± 6 years of age, 41 men) before and 12 months after CRT implantation. In a 16-segment model, the LV lead position was defined based on the segmental strain curve with earliest peak strain, whereas the CRT system was programmed to pure LV pacing. Nonviability of a segment (transmural scar formation) was assumed if the peak systolic circumferential strain was >-11.1%. In 47 patients, the LV lead was placed in a viable segment, and in 18 patients, it was placed in a nonviable segment. At 12-month follow-up there was greater decrease of LV end-diastolic volumes (58 ± 13 ml vs. 44 ± 12 ml, p = 0.0388) and greater increase of LV ejection fraction (11 ± 4% vs. 5 ± 4%, p = 0.0343) and peak oxygen consumption (2.5 ± 0.9 ml/kg/min vs. 1.7 ± 1.1 ml/kg/min, p = 0.0465) in the viable compared with the nonviable group. The change in LV ejection fraction and the reduction in LV end-diastolic volumes at follow-up correlated to an increasing peak systolic circumferential strain in the segment of the LV pacing lead (r = 0.61, p = 0.0274 and r = 0.64, p = 0.0412, respectively). Considering only patients with ischemic heart disease, differences between viable and nonviable LV lead position group were even greater. Preserved viability in the segment of the CRT LV lead position results in greater LV reverse remodeling and functional benefit at 12-month follow-up. Deformation imaging allows analysis of viability in the LV lead segment.

Left ventricular remodeling and mitral valve surgery: Prospective study with real-time 3-dimensional echocardiography and speckle tracking

The aim of the present study was the assessment of left ventricular (LV) remodeling during the surgical management of degenerative mitral valve regurgitation (DMR) with the application of 2 emerging imaging modalities: real-time 3-dimensional echocardiography (3DE) and speckle tracking. A total of 40 patients with DMR were prospectively recruited. Two-dimensional echocardiography, 3DE, and speckle tracking studies were performed before surgery and 6 months postoperatively. The LV volumes, stroke volume, and ejection fraction were calculated. The strain of all myocardial segments, as well as dyssynchrony, was assessed. Receiver operating characteristic curves and regression analysis were used to assess the independent predictors of mitral regurgitation recurrence and LV remodeling. Of the 40 patients, 21 underwent mitral valve repair and 19 valve replacement. Their mean age was 59.5 ± 15.4 years. The postoperative LV 3DE analysis revealed a significant reduction in LV end-diastolic volume (103.9 cm(3) from 165.2 cm(3) preoperatively, P < .001). A synchronous decrease in the LV end-diastolic diameter (48 mm from 53.5 mm preoperatively, P < .001) and left atrial diameter (42.8 mm from 53.1 mm preoperatively, P = .005) were identified after DMR surgery. Regression analysis demonstrated incremental favor toward mitral valve repair in reverse ventricular remodeling. Independent factors were identified for regurgitation recurrence after surgery. The most significant were late diastolic (A') wave of the septal apical wall of < 3.2 cm/s (area under the curve [AUC], 0.82), late diastolic (A') wave of the mid-septal wall of ≤ 3.66 cm/s (AUC, 0.82), mid-lateral radial strain of ≤ -27 (AUC, 0.81), and apical lateral radial strain of ≤ -25 (AUC, 0.80). 3DE and speckle tracking proved to be important imaging tools in assessing reverse LV remodeling after DMR surgery. Subtle regional preoperative changes in diastolic function of the septal and lateral wall could be identified preoperatively, aiding in optimizing the referral timing and recognizing potential culprits as indicators of disease recurrence after mitral repair.

Acute volume infusion preserves left ventricular end diastolic volume during combined heat and simulated hemorrhage

Heat stress compromises blood pressure (BP) control during a simulated hemorrhagic challenge, while acute volume loading attenuates this response. This study tested the hypothesis that the mechanism of preserved BP control during heat stress + volume loading is, in part, through preservation of left ventricular end diastolic volume (LVEDV). LVEDV was measured in nine subjects during normothermia (NT), after an increase in pulmonary artery blood temperature of 1.3 ± 0.2 °C (HS; P &lt; 0.05), and after volume infusion (HS + Inf). In each condition, supine LVEDV was assessed via echocardiography, by the Simpson biplane method, prior to and during simulated hemorrhage, evoked via 30 mmHg lower body negative pressure (LBNP). LVEDV was reduced by HS (NT: 148 ± 26 ml, HS: 126 ± 31 ml; P &lt; 0.05), however, this fall was attenuated by HS + Inf (HS + Inf: 133 ± 25 ml; P &gt; 0.05 relative to NT and HS). During simulated hemorrhage, the reductions in LVEDV were similar between NT (45 ± 20 ml) and HS (52± 20 ml), whereas the reduction in LVEDV after volume infusion (22 ± 22 ml) was attenuated relative to NT and HS (P &lt; 0.05). Importantly, infusion resulted in an LVEDV during LBNP that was significantly elevated (111 ± 26 ml) relative to HS alone (74 ± 25 ml). Improved control of BP following volume infusion during HS occurs in part by attenuating the reduction in LVEDV to a simulated hemorrhagic challenge.Supported by NIH Grant NIH‐HL61388 &amp; HL84072

Effets de la réduction de la précharge sur les paramètres échographiques de la fonction systolique et diastolique du ventricule gauche de l’enfant en insuffisance rénale terminale : étude comparative avant et après hémodialyse

Purpose Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children. Methods Thirty-five children with chronic renal failure (15 males, aged 12.8 ± 3.8 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. Results Hemodialysis led to reduction in LV end-diastolic volume ( p = 0.001), end-systolic volume ( p = 0.05), left atrium area ( p < 0.0001), peak early (E wave) transmitral flow velocity ( p = 0.005), peak S velocity of pulmonary vein flow ( p = 0.002), aortic time velocity integral ( p < 0.0001) and aortic ejection time ( p < 0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly ( p = 0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly ( p = 0.042) after hemodialysis. Conclusions Most of Doppler-derived indices of diastolic function are preload-dependant. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.

Theoretic Impact of Infarct Compliance on Left Ventricular Function

After coronary occlusion, the infarct region loses contractile function immediately and then undergoes a progressive healing process. This causes complex and time-dependent changes in infarct material properties that have not been well described experimentally. We used a theoretic approach to assess how infarct compliance effects left ventricular (LV) size and function after myocardial infarction. We used a closed-loop lumped-parameter model of the ovine cardiovascular system developed to study the effect of infarct size and compliance on cardiovascular function. The time-varying LV function was partitioned into infarct and noninfarct regions where the parameters of each could be adjusted separately. The model incorporated an adaptive compensatory mechanism to maintain stroke volume by varying the total blood volume. For the preinfarction heart, the model produced pressure, volume, and functional results that were consistent with normal values for large animals. When infarcts of progressively larger size (5% to 25%) were introduced and stroke volume adaptation was permitted, the model produced pressure, volume, and functional results that were consistent with postinfarction values measured experimentally in large animals. Infarct size was held at 20% as infarct compliance decreased from 7 to 1 mL/mm Hg. This stiffening of the infarct resulted in reduced LV end-diastolic volume (200 to 60 mL), increased ejection fraction (0.10 to 0.30), and reduced LV end-diastolic pressure (14 to 5 mm Hg). Estimated LV oxygen consumption was also improved in the stiffer infracts. Stiffer infarcts are associated with less LV dilatation, reduced filling pressures and better global LV function.

Haemodialysis: effects of acute decrease in preload on tissue Doppler imaging indices of systolic and diastolic function of the left and right ventricles

Conventional echocardiographic (ECHO) parameters of left ventricular (LV) and right ventricular (RV) systolic and diastolic function have been shown to be load-dependent; however, the impact of preload reduction on tissue Doppler (TD) parameters of LV and RV function is incompletely understood. The aim of this study was to examine the effect of acute preload reduction by haemodialysis (HD) on conventional (ECHO) and TD imaging (TDI) indices of systolic and diastolic function of the left and right ventricles. Seventeen chronically uremic patients (age 31 +/- 10 years), without overt heart disease underwent conventional 2D and Doppler ECHO together with measurement of longitudinal mitral and tricuspid annular motion velocities. Fluid volume removed by HD was 2706 +/- 1047 cm(3). Haemodialysis led to reduction in LV end-diastolic volume (P < 0.0001), end-systolic volume (P < 0.001), peak early (E wave) transmitral flow velocity (P = 0.0001), and the ratio of early to late Doppler velocities of diastolic mitral inflow (P = 0.021). For the LV, early diastolic (E0) TDI velocities and the ratio of early to late TDI diastolic velocities (E0/A0) only on the septal side of the mitral annulus decreased significantly after HD (P = 0.0001 and P = 0.009, respectively). In a subgroup of seven patients who sustained significantly larger fluid volume loses following HD, E0 and the ratio of E0/A0 at the lateral side of mitral annulus also decreased suggesting a greater resistance of the lateral annulus to preload changes. Systolic velocities decreased after HD on both sides of mitral annulus (septal 6.90 +/- 1.10 vs. 5.97 +/- 1.48 cm/s, P = 0.006; lateral 8.68 +/- 2.67 vs. 6.94 +/- 1.52 cm/s, P = 0.011). For the RV, systolic tricuspid annular velocities decreased (13.45 +/- 1.47 vs.11.73 +/- 1.90 cm/s, P = 0.002) together with early diastolic velocities after HD (13.95 +/- 2.90 vs.10.62 +/- 2.45 cm/s, P = 0.0001). Both systolic and early diastolic tricuspid annular velocities correlated directly with fluid removal (P < 0.01). This study shows that both systolic and diastolic TDI velocities of the LV and RV are preload-dependent. However, the lateral mitral annulus is more resistant to preload changes than either the septal mitral annulus or the lateral tricuspid annulus.