Systolic Pulmonary Venous Flow Research Articles

The relationship of interleukin-6 and C-reactive protein with left ventricular geometry and function in patients with obstructive sleep apnea syndrome and pre-hypertension.

To assess the relationship of interleukin-6 (IL-6) and C-reactive protein (CRP) levels with left ventricular geometry (LVG) and function in patients with obstructive sleep apnea syndrome (OSAS) and pre-hypertension. A total of 458 patients were assigned into four groups: normal geometry (NG), concentric remodeling (CR), eccentric hypertrophy (EH), and concentric hypertrophy (CH). Pearson correlation and multivariate logistic regression analyses were used to determine the correlation between IL-6, CRP, and clinical, polysomnographic, and biochemical parameters with LVG and function. IL-6 and CRP levels were higher in the EH and CH groups than those in the NG and CR groups. The results of the Pearson correlation analysis showed that IL-6 level was positively correlated with the E/e' ratio and peak systolic pulmonary venous reverse velocity (PVa) duration time (PVaD), while negatively correlated with the E/A ratio, s', and left ventricular ejection fraction (LVEF). CRP level was positively correlated with A-wave duration time (AD), peak systolic pulmonary venous flow velocity (PVs), PVa and PVaD, while negatively correlated with the E/A ratio. The results of the multivariate logistic regression analysis revealed that IL-6 and CRP levels were correlated with EH (β=1.213, odds ratio [OR]=3.363, p<0.001; β=1.258, OR=3.518, p<0.001) and CH (β=.938, OR=2.555, p=0.008; β=1.239, OR=3.454, p<0.001). IL-6 and CRP levels are associated with LVG and function, suggesting that IL-6 and CRP levels are involved in OSAS and pre-hypertension, leading to abnormal left ventricular structure and function.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa with fistulous communication to the left atrium causing congestive heart failure.

Pseudoaneurysms of the mitral‐aortic intervalvular fibrosa can rupture and form fistulous communications between the left ventricle and left atrium. Pulmonary venous systolic flow reversal in such cases reflects elevated left atrial pressure due to shunting. This finding, particularly in the setting of endocarditis, is not specific for severe mitral regurgitation.

Prevalence, distribution, and determinants of pulmonary venous systolic flow reversal in severe mitral regurgitation.

This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters. A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n = 72), ventricular functional MR (V-FMR) (n = 20), and atrial functional MR (A-FMR) (n = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC). All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC.

Relation Between Pulmonary Venous Flow and Left Atrial Pressure During Percutaneous Mitral Valve Repair With the MitraClip

Pulmonary venous (PV) flow may provide valuable information in terms of the severity of mitral regurgitation and left atrial (LA) pressure. We sought to find PV flow determinants of LA pressure during MitraClip procedure. We analyzed 575 PV flows in 290 patients using transesophageal echocardiography before and after MitraClip procedure. We measured peak systolic velocity (Sv), diastolic velocity (Dv), systolic velocity time integral (Svti), diastolic velocity time integral (Dvti), and those systolic to diastolic ratio as PV flow parameters. Systolic PV flow velocity was lower than diastolic PV flow velocity before the procedure, but systolic PV flow velocity markedly increased after the procedure. Peak Sv/Dv ratio and Svti/Dvti ratio after the procedure were significantly higher than those before the procedure (peak Sv/Dv; 1.06 [inter-quartile range (IQR) 0.73 to 1.34] vs 0.32 [IQR 0.03 to 0.55], p <0.001, Svti/Dvti; 1.06 [IQR 0.76 to 1.61] vs 0.26 [IQR 0.02 to 0.51], p <0.001). Peak Sv/Dv ratio and Svti/Dvti ratio were negatively correlated with mean LA pressure and LA pressure V wave, respectively (peak Sv/Dv ratio; r = -0.50 and r = -0.59, Svti/Dvti ratio; r = -0.47 and r = -0.58, p <0.001). In receiver operating characteristics curve assessing the ability of PV flow to predict mean LA pressure ≥20 mm Hg after the successful procedure, the area under the curve of peak Sv/Dv ratio was 0.76 (p <0.001). Peak Sv/Dv ratio <0.98 best predicted LA pressure ≥20 mm Hg with 77% sensitivity and 71% specificity. In conclusion, systolic PV flow velocity immediately increased in response to mitral regurgitation reduction during MitraClip procedure. PV flow velocity, specifically systolic to diastolic ratio, was useful to evaluate invasively determined LA pressure.

Abstract 14797: Impact of Normalized Pulmonary Vein Flow Pattern After Percutaneous Mitral Valve Repair

Background: Systolic reverse pulmonary venous flow (PVF) assessed with pulsed Doppler echocardiography is a valuable marker of severe mitral regurgitation (MR). However, the relationship between PVF pattern after MR reduction by percutaneous mitral valve repair with MitraClip system and clinical outcome is not well established. We hypothesized that normalized PVF after MitraClip procedure was associated with successful MR reduction and clinical outcome. Method: 146 consecutive patients with symptomatic MR who implanted the MitraClip were studied. The patients were divided into 2 groups on the basis of post-procedural left upper PVF pattern; the normalized group (n = 77) and the non-normalized group (n = 69). The normalized PVF was defined as a ratio of peak systolic to diastolic flow velocity ≧1. Results: In baseline characteristics, the normalized PVF was independently associated with age &lt;75 (liner regression coefficient [B] = 0.521, 95% confidence interval [CI] = 0.146 - 0.822, P = 0.016) and degenerative MR (B = 0.969, 95% CI 0.049 - 0.383, P &lt;.0001). The normalized group demonstrated significantly higher residual MR ≦2 rate than non-normalized group (100% vs. 97.3%, P = 0.003). At a mean of 2.9 ± 1.9 years follow up, the rate of freedom from the composite endpoint (defined as surgery or 2nd MitraClip procedure for mitral valve dysfunction or all cause death) was significantly higher in the normalized group. Mutivariable Cox regression analysis demonstrated that normalized PVF was an independent post-procedural parameter of freedom from composite endpoint (hazard ratio =0.571, 95%CI 0.339 - 0.948, P = 0.03). Conclusion: The normalized PVF after the MitraClip procedure was associated with successful MR reduction and a long-term clinical outcome. Prospective data should be used to validate this.

Echocardiographic Parameters Associated With Asymmetrical Structural Remodeling In Patients With Or Without Atrial Fibrillation.

Left atrial (LA) dilation can evolve into asymmetrical remodeling. The aim of this study was to determine the echocardiographic parameters associated with LA asymmetric structural remodeling (ASR) in patients with and without nonvalvular atrial fibrillation (AF). A total of 170 patients with a dilated LA were prospectively enrolled. ASR was defined as an atrium shape that is no longer ellipsoidal (LA basal dimension measured at the junction between the pulmonary vein and atrium greater than the mitral annular dimension). Symmetric structural remodeling (SSR) was defined as all other cases. Echocardiographic parameters of LA function and left ventricular diastolic function, measured by pulsed-wave Doppler and Tissue Doppler Imaging, were analyzed to identify the parameters associated with ASR. The mean age of the patients was 67 ± 11 years. Forty-one percent had a stable sinus rhythm (SR), and 59% had AF. LA-ASR was detected in 66% of the patients: 55% with AF and 45% with SR (p=0.002). The mean LA-ASR and LA-SSR volume indexes were 49 ± 14 ml/m² and 29 ± 13 ml/m², respectively (p<0.001). LA systolic myocardial velocity (p=0.036) and peak systolic pulmonary venous flow velocity (p=0.033) were the parameters best associated with ASR. The sensitivity and specificity of both parameters, based on ROC curve analysis, were 77 and 70%, respectively. The AUC was 0.765 (95% CI: 0.662-0.849, p=0.0001). LA dilation is associated with a great number of asymmetrical structural remodeling. Echocardiographic parameters that reflect LA reservoir function are best associated with asymmetrical remodeling.

Abstract 8846: Relationship Between Left Appendage Volume and Function, and Left Atrial Function: A Real-Time Three-Dimensional Transesophageal Echocardiography Study

Background: Left atrial appendage (LAA) has multilobed complicated structure. Therefore, attempts to quantitate LAA size and function by 2-dimensional (2D) methods may not offer acurate evaluations. Recent development of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) has enabled us to examine morphology and to determine absolute volumes of LAA without geometrical assumptions. The association between LAA volume and function, and left ventricular (LV) and left atrial (LA) function has not been well investigated. Methods: Eighty-nine pts who underwent RT3D-TEE for evaluation of thrombus in LAA were studied. All measurements were performed off-line software. LAA maximal (max) orifice area, max and minimal (min) volumes, and ejection fraction (LAAEF) were assessed (Figure). LAA emptying flow velocity was also measured. We determined max and min LV and LA volume (LAV) by the Simpson method with 2D transthoracic echocardiography. LAV total emptying fraction (LAEF) was determined as (max LAV - min LAV)/ max LAV. Similarly in pts with sinus rhythm, active and passive LAEF were calculated. Pulsed Doppler E, tissue Doppler E' and E/E' were also measured. Additionally, as a parameter of LA compliance, we measured time velocity integral of systolic pulmonary venous flow (SVTI). Results: LAA volume was significantly correlated with max LAV, min LAV, E/E' and SVTI. LAAEF was significantly correlated with age, all LAEFs, E/E' and SVTI. There was no correlation between LAA volume and LAAEF (Table). Multiple regression analysis revealed that max LAV and E/E' (both, p&lt;0.01) were independently correlated with 3D derived LAA volume, and active and passive LAEF were independently correlated with 3D derived LAAEF (p=0.02 and p=0.05, respectively). Conclusion: LAA volume determined by RT3D-TEE was independently associated with E/E' and max LA volume. Moreover, LAA function was independently associated LA function.

Left atrial flow propagation velocity: a new approach for assessment of left atrial reservoir function

To assess the feasibility of left atrial flow propagation velocity (LAFPV) measurement and to evaluate the influence of preload alterations on this new parameter of left atrial (LA) reservoir function as compared to conventional echocardiographic indices. 30 healthy volunteers (26 ± 5 years, 20 males) underwent echocardiographic examination at rest, during passive leg lifting and after sublingual administration of nitroglycerine with subsequent Valsalva maneuver. LA reservoir function was assessed by conventional indices including LA expansion index, peak velocity and velocity-time integral of pulmonary venous systolic flow. As well, LAFPV was measured by color M-mode in an apical 4-chamber view as the slope of the transatrial flow wave during LA reservoir phase. LAFPV measurement was feasible in 25 subjects (83%). All conventional parameters of LA reservoir function were significantly altered from resting values by both load-modifying conditions. However, LAPFV was not significantly altered by such maneuvers (228 ± 28 cm s⁻¹ at rest vs. 238 ± 3 cm s⁻¹ during leg lifting, P = NS, vs. 218 ± 38 cm s(-1) after nitroglycerin with Valsalva maneuver, P = NS vs. rest, P < 0.01 vs. leg lifting). LAFPV can be measured in a majority of subjects and represents a new, less load-dependent index of LA reservoir function that may more appropriately reflect LA compliance.

Padrões ecocardiográficos do fluxo venoso pulmonar nas malformações cardíacas congênitas com hiperfluxo pulmonar

To describe pulmonary venous flow patterns using transthoracic echocardiograms on children suffering from different congenital heart defects with increased pulmonary flow. Prospective study and consecutive selection of children suffering from congenital heart defects with increased pulmonary flow. The transthoracic, apical view, Doppler echocardiogram was used, positioning the sample-volume at the lower pulmonary vein, 4mm from its junction with the left atrium. The data analyzed included: dominant systolic or diastolic pulmonary venous flow and atrial contraction waveform characteristics, designated as "A" for absent and "R" for reversed. The study included twenty-nine patients with a mean age of 29.9 +/- 58.9 months, suffering from the following congenital heart conditions: interatrial and interventricular communication defects, patent ductus arteriosus, atrioventricular septal defects, total transposition of the great arteries and truncus arteriosus. All the patients presented a continuous pattern of high velocity pulmonary venous flow. Nine patients presented a dominant systolic waveform (31%), eighteen presented a dominant diastolic wave form (62%) and 2 patients had systolic and diastolic wave forms of equal amplitude (7%). Six patients (21%) presented a R atrial contraction waveform and 23 (79%) presented an A atrial contraction waveform. Congenital heart diseases with increased pulmonary flow present a continuous pattern of high velocity pulmonary venous flow with alterations mainly in the atrial contraction reversal pattern.

Relationship between Slow Coronary Flow and Left Atrial Appendage Blood Flow Velocities

This study was undertaken to assess whether slow coronary flow (SCF)is related to low left atrial appendage (LAA) blood flow velocities. Study subjects consist of 44 patients with SCF and 11 volunteer subjects with normal coronary angiogram. The diagnosis of SCF was made using the TIMI frame count method. The blood flow velocities were obtained by placing a pulsed-wave Doppler sample volume inside the proximal third of the LAA. The mean LAA emptying velocities (MEV)were significantly lower in patients than control subjects (34.5 +/- 9.9 cm/sec vs 84.0 +/- 12.1 cm/sec; P < 0.001). In bivariate analysis, significant correlation was found between MEV, and systolic pulmonary venous flow, mean TIMI frame count, deceleration time, and isovolumetric relaxation time (P < 0.05). By multiple linear regression analysis, mean TIMI frame count (beta=-0.865, P < 0.001) was identified as independent predictors of MEV. This study indicates that SCF phenomenon may be related to low LAA blood flows.

Assessment of Diastolic Function by Doppler Echocardiography in Normal Doberman Pinschers and Doberman Pinschers with Dilated Cardiomyopathy

Assessment of diastolic function in patients with dilated cardiomyopathy (DCM) has the potential to add valuable information regarding hemodynamics, disease severity, and prognosis. The purpose of this study was to determine transmitral flow (TMF), isovolumic relaxation time (IVRT), pulmonary venous flow (PVF), flow propagation velocity (Vp), and mitral annular velocities by tissue Doppler in Doberman Pinschers with and without DCM. It was anticipated that normal and DCM Dobermans would differ with respect to these parameters, and that associations with time to congestive heart failure (CHF) or death would be found. Thirty client-owned Doberman Pinschers (10 each of normal, occult DCM, and overt DCM) were studied. Each dog underwent echocardiography with or without thoracic radiography (to confirm CHF) for classification as normal or DCM-affected, followed by collection of echocardiographic diastolic parameters. The group with occult DCM exhibited features of pseudonormal TMF, reduced systolic to diastolic PVF ratio, and reduced Vp. Shorter early TMF deceleration time (DTE) was associated with shorter time to CHF or sudden death. The group with overt DCM exhibited restrictive TMF, blunted systolic PVF, and reduced early and late diastolic mitral annular velocities. Doberman Pinschers showed evidence of moderate and severe diastolic dysfunction in occult and overt DCM, respectively. Short DTE may be a useful predictor of onset of CHF or sudden death.

Effects of Preemptive Enoximone on Left Ventricular Diastolic Function After Valve Replacement for Aortic Stenosis

Left ventricular (LV) hypertrophy is associated with increased diastolic chamber stiffness early after aortic valve replacement for valve stenosis. Enoximone, a phosphodiesterase III inhibitor, has been shown to improve myocardial contractility and relaxation when administered as a single dose after cardiac surgery. The present study investigated, by analysis of transmitral flow velocity patterns and end-diastolic pressure-area relations, whether enoximone administered before aortic valve surgery has an effect on LV diastolic properties. Prospective, randomized study. Referral center for cardiothoracic surgery at a university hospital. Thirty-four patients undergoing aortic valve replacement for aortic stenosis. Patients in the enoximone group (n = 17) received a bolus dose of 0.35 mg/kg (0.15 mg/kg before aortic cross-clamping and 0.2 mg/kg added to the cardioplegic solution). Individual pressure-area relations (pulmonary capillary wedge pressure v left ventricular end-diastolic area) were obtained by using volume loading by leg elevation before and after surgery with closed chest. The pressure-area relation on the pressure-area plot was shifted to the left after surgery, indicating decreased LV diastolic distensibility in the enoximone and control groups and providing evidence of decreased LV diastolic function. Indices of LV diastolic chamber stiffness, LV operating stiffness (K(LV)) derived from the deceleration time of early ventricular filling, and the constant of chamber stiffness (beta) derived from pressure-area relations were not different after enoximone treatment. Systolic LV function was unaltered after cardiac surgery in both groups. Analysis of changes in transmitral flow patterns identified an increased atrial filling fraction in enoximone-treated patients, suggesting increased atrial systolic function. The unaltered systolic pulmonary venous flow velocity compared with the decrease in the control group after volume loading further supports preservation of left atrial reservoir function with enoximone in the absence of evidence for decreased LV stiffness. Preemptive enoximone did not change LV diastolic function based on diastolic filling patterns or LV stiffness indices (K(LV) and beta) derived from Doppler early filling deceleration time and pressure-area relations. Doppler data suggested improvement of left atrial systolic function and preservation of left atrial reservoir function with enoximone.

Echocardiographic Assessment of Left Ventricular Diastolic Function in Transitional Circulation Period

Background and Objectives：During the transitional period from fetal to neonatal life, there are dramatic changes in the newborn circulation. Among these changes, the left ventricular diastolic function can be easily assessed by Doppler measurement of the mitral inflow. However, there are many physiologic and hemodynamic factors responsible for the mitral inflow. This study was designed to evaluate several parameters that represent the left ventricular function during the transitional circulation period. Subjects and Methods：Eighteen normal full-term infants were studied by serial two-dimensional, Doppler and color flow echocardiography within 24 hours before and after birth, between 2 days and 6 days after birth and between 7 days and 30 days after birth). Results：One day after birth, the mitral valve (MV) E velocity and E/A increased (37.9±7.5 vs. 60.3±9.0 and 0.8±0.1 vs. 1.1±0.1, p<0.01, respectively), but the MV A velocity, the velocity of propagation (Vp), the LV isovolumic relaxation time (IVRT), the corrected IVRT and the tissue Doppler ventricular septum e’ and s’ did not change. Although Vp/E and a’ decreased (1.2±0.3 vs. 0.7±0.2 and 8.2±1.8 vs. 6.5±1.7, p<0.05, respectively), the E/e’ and the systolic and diastolic pulmonary venous flow velocities increased after birth (6.3±1.9 vs. 11.6±2.9, and 26.1±6.7 vs. 64.5±9.6, and 20.9±4.1 vs. 63.5±17.2, p<0.05, respectively). Conclusion：Increased preload plays a key role for the increased MV E/A ratio after birth. Other unknown factors (and possibly including pericardial restriction) may be also responsible for left ventricular diastolic function. (Korean Circulation J 2006; 36:652-660) KEY WORD：Diastolic function.

Deceleration time of systolic pulmonary venous flow: a new clinical marker of left atrial pressure and compliance

The curvilinearity of the atrial pressure-volume curve implies that atrial compliance decreases progressively with increasing left atrial (LA) pressure (LAP). We predicted that reduced LA compliance leads to more rapid deceleration of systolic pulmonary venous (PV) flow. With this rationale, we investigated whether the deceleration time (t dec) of PV systolic flow velocity reflects mean LAP. In eight patients during coronary surgery, before extracorporeal circulation, PV flow by ultrasonic transit time and invasive LAP were recorded during stepwise volume loading. The t dec was calculated using two methods: by drawing a tangent through peak deceleration and by drawing a line from peak systolic flow through the nadir between the systolic and early diastolic flow waves. LA compliance was calculated as the systolic PV flow integral divided by LAP increment. Volume loading increased mean LAP from 11 +/- 3 to 20 +/- 5 mmHg (P < 0.001) (n = 40), reduced LA compliance from 1.16 +/- 0.42 to 0.72 +/- 0.40 ml/mmHg (P < 0.004) (n = 40), and reduced t dec from 320 +/- 50 to 170 +/- 40 ms (P < 0.0005) (n = 40). Mean LAP correlated well with t dec (r = 0.84, P < 0.0005) (n = 40) and LA compliance (r = 0.79, P < 0.0005) (n = 40). Elevated LAP caused a decrease in LA compliance and therefore more rapid deceleration of systolic PV flow. The t dec has potential to become a semiquantitative marker of LAP and an index of LA passive elastic properties.

Usefulness of Doppler assessment of pulmonary vein and left atrial appendage flow following pulmonary vein isolation of chronic atrial fibrillation in predicting recovery of left atrial function

Atrial fibrillation (AF) is a widespread condition that causes significant morbidity and mortality. Recently, pulmonary venous (PV) isolation using radiofrequency ablation has been used successfully to exclude the pulmonary venous ostia, resulting in correction of AF. Further, miniaturized high-frequency ultrasound phased-array transducers currently provide Doppler and 2-dimensional imaging during the ablation procedure. We examined atrial function and its determinants using intracardiac echocardiography before and after PV isolation in 45 patients who had chronic AF (56 +/- 11 years old). PV, left atrial (LA) appendage, and mitral and tricuspid flows were recorded. Recovery of booster pump function (defined by the presence of mitral inflow A wave, LA appendage a-wave, and PV A-reversal wave velocities >10 cm/s) was observed in 39 of 45 patients (86.6%). PV flow systolic wave before and after ablation correlated with the degree of LA booster pump function after PV isolation. An early systolic PV flow peak velocity >57.47 cm/s predicted "good" LA booster pump function recovery with 96% specificity. Diastolic LA appendage emptying in AF correlated (p <0.001) and predicted good LA booster pump function with 92% specificity for velocities >46.4 cm/s. Thus, monitoring LA function during PV isolation for chronic AF is feasible. Most patients recovered LA booster pump function immediately after PV isolation, and the degree of recovery correlated with LA reservoir function. Preserved reservoir function during AF is predictive of satisfactory recovery of booster pump function after PV isolation.

Relationship between the frequency of paroxysmal episodes of atrial fibrillation and pulmonary venous flow pattern.

Chronic atrial fibrillation causes mechanical remodelling of the atria, but it is uncertain whether self-terminating episodes of paroxysmal atrial fibrillation (PAF) alter atrial mechanical function during normal sinus rhythm. This study was designed to assess the relationship between the frequency of symptomatic arrhythmic episodes and pulmonary venous flow (PVF) pattern among patients with PAF. The effect of symptomatic arrhythmic episodes on PVF was studied in 85 patients with lone PAF (age 48+/-8 years, 66 men). PVF was measured with transthoracic echocardiography during sinus rhythm. Adequate recordings of PVF were achieved in 81 (95%) patients. Peak systolic PVF had an inverse correlation (r=-0.35, P=0.002) with the frequency of PAF episodes. The peak systolic PVF was 76+/-14 cm/s vs 62+/-12 cm/s (P=0.008) among the quartiles with the most and the least frequent episodes of PAF, respectively. There were no significant differences in the other echocardiographic measurements or demographic variables. Frequent arrhythmic episodes significantly diminished systolic PVF among patients with PAF, suggesting that PAF results in gradual mechanical remodelling of the atrium, which may favour recurrence and perpetuation of AF and/or formation of atrial thrombus.

Pulmonary venous systolic flow: Influence of gravity on pulmonary venous flow velocities assessed in patients with atrial fibrillation

The origin of the pulmonary venous (PV) systolic flow wave is still unclear and could be the atrial relaxation and systolic descent of the atrioventricular plane, which decrease atrial pressure (suction) or raised PV pressure. In atrial fibrillation (AF), loss of atrial contraction and relaxation significantly modifies the systolic PV flow wave. The effect of recumbent positional changes on PV, however, has not yet been characterized in AF. The purpose of this study was to evaluate the effect of positional changes on systolic PV flow in patients with AF studied by transesophageal echocardiography. The study group consisted of 45 patients with AF (34 patients with AF, alone, and 11 patients with mitral stenosis [MS]). To assess the influence of left atrial pressure, we included patients with MS and AF. Pulsed wave Doppler transesophageal echocardiography of the left and right upper PV were performed in the left lateral recumbent position in all patients and repeated records were obtained with the subject in the supine position in 25 (AF alone: n = 20, MS: n = 5) of 45 patients. In the left lateral recumbent position, the systolic PV flow velocity and systolic fraction of the left PV, which were recorded on the recumbent subject's lower side, were significantly increased compared with those of the right PV in both AF alone and MS with AF (33.9 ± 10.8 vs 13.8 ± 6.4 cm/s, 0.45 ± 0.09 vs 0.20 ± 0.10 in AF alone; 30.2 ± 11.7 vs 14.6 ± 6.0 cm/s, 0.43 ± 0.12 vs 0.20 ± 0.07 in MS, respectively, P < .01). By changing the position from the left lateral to the supine position, systolic PV flow velocity and systolic fraction of the left and right PV became the same (29.3 ± 8.4 vs 27.9 ± 8.4 cm/s, 0.39 ± 0.09 vs 0.36 ± 0.06 in AF alone, 23.5 ± 8.8 vs 27.5 ± 5.0 cm/s, 0.35 ± 0.08 vs 0.35 ± 0.09 in MS, respectively). These findings show that the PV volume (hydrostatic pressure) significantly modifies systolic PV flow wave in patients without atrial contraction and relaxation. We should take into consideration the body position on which PV flow is studied. (J Am Soc Echocardiogr 2002;15:1087-93.)

Losartan treatment and left ventricular filling during volume loading in patients with dilated cardiomyopathy

Background Patients with mild heart failure show a reduction in preload reserve mechanism during volume expansion. At this time, the effects of volume expansion on left ventricular (LV) diastolic filling in this subset of patients have not been well characterized. Methods We evaluated the effects of acute volume loading on Doppler parameters of LV filling in 10 healthy control subjects and in 12 patients with idiopathic dilated cardiomyopathy (DCM). In patients with DCM, the effects of losartan on diastolic adaptation to volume load were also investigated. Results During volume loading, the healthy control subjects showed a decrease in isovolumic relaxation time (F = 5.3, P <.05) but an increase in the LV peak filling rate (F = 52.9, P <.001) and velocity time integral of both systolic (F = 72.8, P <.001) and diastolic (F = 4.6, P <.05) pulmonary venous flow. In patients with DCM, isovolumic relaxation time decreased more than in control subjects (F = 8.1, P <.01), and the deceleration time of the early mitral wave was reduced (F = 26.3, P <.001). Furthermore, the duration of pulmonary venous flow reversal exceeded that of mitral flow at atrial contraction (F = 28.5, P <.001). After treatment with losartan, the deceleration time of early mitral wave remained unchanged, and the duration of pulmonary venous flow reversal at atrial contraction did not exceed that of mitral flow; thus, a significant treatment effect was detectable (F = 5.6, P <.05; and F = 6.6, P <.05, respectively). Conclusions Control subjects respond to volume load with enhancement in early LV filling, whereas patients with DCM show an increase of LV filling pressure. Diastolic adaptation to volume load improves in patients with DCM after treatment with losartan. (Am Heart J 2002;143:433-40)

Echocardiography diagnosis of diastolic heart failure

Left ventricular diastolic dysfunction can be diagnosed if clinical signs of heart failure and normal ejection fraction are found. Beside clinical signs of heart failure and criteria from catheterization studies like abnormal left ventricular relaxation, filling and/or compliance echocardiography provides valuable parameters for the assessment of diastolic dysfunction. By the use of various parameters diastolic dysfunction can be differentiated into four degrees of severity, which are of great prognostic importance. If more than one echocardiographic parameter is used, sensitivity for the assessment of diastolic dysfunction becomes nearly 100%. Conventional parameters include isovolumetric relaxation time (IVRT) measured by pulsed Doppler, the ratio of rapid filling and atrial filling velocity (E/A), deceleration time of rapid mitral inflow as well as the ratio of systolic and diastolic pulmonary venous flow velocities. In patients with signs of diastolic heart failure and a normal E/A ratio pulmonary venous flow pattern can help to unmask "pseudonormalization" as the transition from abnormal relaxation to restriction. These parameters, however, are preload-dependent and do not provide intrinsic left ventricular properties. Even in atrial fibrillation, left ventricular filling pressure can be assessed. Two novel approaches, color Doppler M-mode of left ventricular inflow and tissue Doppler of the mitral annulus, are relatively preload-independent and allow direct estimation of relaxation and filling pressure. By the means of real-time 3-D echocardiography we developed a new method for the non-invasive assessment of rapid filling rate (PFR), thereby completing the echocardiographic approaches to determine diastolic dysfunction. The broad spectrum of approaches available today makes echocardiography the first choice for the assessment of diastolic dysfunction.

Accurate determination of mitral regurgitation by assessing its influence on the combined diastolic mitral and pulmonary venous flow: just 'looking twice'.

To assess the diagnostic accuracy of combined transmitral E wave velocity and reversed systolic pulmonary venous flow for the quantification of mitral regurgitation severity. Measuring forward and total left ventricular stroke volume, mitral regurgitation severity was assessed quantitatively by calculating the regurgitant fraction in 106 consecutive patients with pure mitral regurgitation. According to the regurgitant fraction, the optimal E wave velocity for accurate distinction of mild to moderate and more than moderate mitral regurgitation was chosen by calculating the receiver-operating characteristic plot. Severe mitral regurgitation was defined by reversed systolic pulmonary venous flow. Combining transmitral E wave velocity and reversed systolic pulmonary venous flow had an overall accuracy of 78% (95% CI 70--86%) for classification of mitral regurgitation severity. E wave velocity >1.0ms(-1) predicted more than moderate mitral regurgitation with 78% sensitivity (95% CI 69-86%) and 90% specificity (95% CI 82--95%), resulting in a positive likelihood ratio of 8.1 (95% CI 5--15) and negative likelihood ratio of 0.25 (95% CI 0.18--0.35). For reversed systolic pulmonary venous flow in the presence of increased E wave velocity, the sensitivity and specificity to detect severe mitral regurgitation was 78% (95% CI 69--86%) and 97% (95% CI 92--99%) with the corresponding positive and negative likelihood ratio of 29 (95% CI 11--96) and 0.22 (95% CI 0.14--0.31). Test accuracy was independent of systolic function in a multivariate regression analysis. 'Looking twice', once at the transmitral E wave velocity and once at pulmonary venous flow in patients with mitral regurgitation, allows accurate determination of moderately severe and severe mitral regurgitation.