Tissue Doppler Mitral Annular Velocity Research Articles

Abstract 16414: Prognostic Value of Exercise Tolerance and Exercise-Associated Diastolic Dysfunction in Elderly Patients Referred for Exercise Stress Echocardiography

Aim: We studied the prognostic value of exercise tolerance, measured in metabolic equivalents of tasks (METs), and exercise-associated diastolic dysfunction (Ex-DD) in elderly patients referred for exercise stress echocardiography (ExE). Methods: Retrospectively, 583 patients (70±6 years, 57% women, EF: 61±5%) who underwent ExE using the Bruce protocol and were ≥60 years of age were included and followed for death or cardiac hospitalization. Ex-DD was defined as the presence of abnormal resting tissue Doppler mitral annular velocity (e') and post-exercise E/e' ratio. Results: During a median follow-up period of 3.7 years, 13 patients died, 70 were hospitalized, and 77 had combined outcome. 151 (26%) patients had Ex-DD and had more combined outcome compared to no Ex-DD (29 [19%] vs. 48 [11%], p=0.01). The average workload during ExE was 8.3±2.8 METs. Receiver operating characteristic curve identified that METs <8.5 best predicts the combined outcome. As such, patients were classified into 260 with METs ≥ 8.5 and 323 with METs < 8.5. Patients with METs < 8.5 were older, had worse risk profiles, poorer resting and post-exercise diastolic variables, more Ex-DD (32% vs. 19%, p<0.001), and more outcomes (55 [17%] vs. 22 [9%], p=0.002) compared to METs ≥ 8.5. Both Ex-DD (HR: 1.9, 95% CI: 1.2-2.9) and METs < 8.5 (HR: 1.9, 95% CI: 1.1-3.1) independently predicted the combined outcome. The presence of both METs < 8.5 and Ex-DD conferred the highest risk (HR: 2.9, 95% CI: 1.5-5.6) and remained significant after adjustment and propensity score matching, while the presence of either alone carried an intermediate risk (HR: 1.9, 95% CI: 1.1-3.5), which became non-significant after adjustment and matching. Conclusions: poor exercise capacity is associated with an adverse prognosis, irrespective of resting or Ex-DD. METs < 8.5 had particularly poor prognosis when combined with Ex-DD, while either alone did not predict outcomes.

Effect of ingesting carbohydrate only or carbohydrate plus casein protein hydrolysate during a multiday cycling race on left ventricular function, plasma volume expansion and cardiac biomarkers

Multiday racing causes mild left ventricular (LV) dysfunction from day 1 that persists on successive days. We evaluated ingesting casein protein hydrolysate-carbohydrate (PRO) compared with carbohydrate-only (CHO) during a 3-day mountain bike race. Eighteen male cyclists were randomly assigned to ingest 6.7% carbohydrate without (CHO) or with 1.3% casein hydrolysate (PRO) during racing (~ 4-5h/day; 68/71/71km). Conventional LV echocardiography, plasma albumin content, plasma volume (PV) and blood biomarkers were measured before day 1 and post race on day 3. Fourteen cyclists (n = 7 per group) completed the race. PV increased in CHO (mean increase (95% CI), 10.2% (0.1to 20.2)%, p = 0.045) but not in PRO (0.4% (- 6.1 to 6.9)%). Early diastolic transmitral blood flow (E) was unchanged but deceleration time from peak E increased post race (CHO: 46.7 (11.8to 81.6)ms, p = 0.019; PRO: 24.2 (- 0.5 to 48.9)ms, p = 0.054), suggesting impaired LV relaxation. Tissue Doppler mitral annular velocity was unchanged in CHO, but in PRO septal early-to-late diastolic ratio decreased (p = 0.016) and was compensated by increased lateral early (p = 0.034) and late (p = 0.012) velocities. Systolic function was preserved in both groups; with increased systolic lateral wall velocity in PRO (p = 0.002). Effect size increase in serum creatine kinase (CK) activity, CK-MB and C-reactive protein concentrations was less in PRO than CHO (Cohen's d mean ± SD, PRO: 2.91 ± 2.07; CHO: 7.56 ± 4.81, p = 0.046). Ingesting casein hydrolysate with carbohydrate during a 3-day race prevented secondary hypervolemia and failed to curb impaired LV relaxation despite reducing tissue damage and inflammatory biomarkers. Without PV expansion, systolic function was preserved by lateral wall compensating for septal wall dysfunction.

Cardioprotective Effects of Carvedilol in Inhibiting Doxorubicin-induced Cardiotoxicity.

Anthracyclines (ANTs) are a class of active antineoplastic agents with topoisomerase-interacting activity that are considered the most active agents for the treatment of breast cancer. We investigated the efficacy of carvedilol in the inhibition of ANT-induced cardiotoxicity. In this randomized, single-blind, placebo-controlled study, 91 women with recently diagnosed breast cancer undergoing ANT therapy were randomly assigned to groups treated with either carvedilol (n = 46) or placebo (n = 45). Echocardiography was performed before and at 6 months after randomization, and absolute changes in the mean left ventricular ejection fraction, left ventricular end diastolic volume, and left ventricular end systolic volume were determined. Furthermore, the percentage change in the left atrial (LA) diameter and other variables of left ventricular (LV) diastolic function, such as transmitral Doppler parameters, including early (E wave) and late (A wave) diastolic velocities, E/A ratio and E wave deceleration time, pulmonary venous Doppler signals, including forward systolic (S wave) and diastolic (D wave) velocities into LA, late diastolic atrial reversal velocity, and early diastolic tissue Doppler mitral annular velocity (e') were measured. In addition, tissue Doppler mitral annular systolic (s') velocity, as a marker of early stage of LV systolic dysfunction, E/e' ratio, as a determinant of LV filling pressure, and troponin I level, as a marker of myocardial necrosis were measured. At the end of follow-up period, left ventricular ejection fraction did not change in the carvedilol group. However, this parameter was significantly reduced in the control group (P < 0.001). Echocardiography showed that both left ventricular end systolic volume and LA diameter were significantly increased compared with the baseline measures in the control group. In pulse Doppler studies, pulmonary venous peak atrial reversal flow velocity was significantly increased in the control group. Moreover, a significant decrease in the mitral annuli early diastolic (e') and peak systolic (s') velocities and a significant increase in the E (the peak early diastolic velocity)/e' ratio in the control group were also observed. However, none of these variables were adversely changed at the end of follow-up in the carvedilol group. Furthermore, the TnI level was significantly higher in the control group than in the carvedilol group (P = 0.036) at 30 days after the initiation of chemotherapy. Prophylactic use of carvedilol may inhibit the development of anthracycline-induced cardiotoxicity, even at low doses.

Relation of Global Longitudinal Strain with Tissue Doppler Mitral Annular Velocities and Left Ventricular Length

Longitudinal left ventricular (LV) systolic function is impaired in heart failure with preserved ejection fraction (EF), with reductions reported in both global longitudinal strain (GLS) and the peak systolic velocity of mitral annular motion (s‘) using tissue Doppler imaging (TDI). However, the significance of GLS versus s’ is incompletely understood. To investigate whether LV end-diastolic length (LVEDL), mitral annular systolic excursion (MASE) and heart rate might moderate the relationship between GLS and s’ we studied subjects with a low peak early diastolic TDI velocity (e‘) but normal EF. GLS was measured using speckle tracking. TDI measurements were averages from the septal and lateral walls. There were 88 subjects of age 66±8 years, (31 males, 64 with hypertension and 54 with diabetes) with septal and lateral e’ < 6 cm/s. The body mass index (BMI) was 29.1±4.1 kg/m2, heart rate was 72±9/min, blood pressure was 137±17/80±10 mmHg, EF was 61±6%, GLS was -17.4±2.7%, septal and lateral s’ were 6.1±1.1 and 6.8±1.5 cm/s, respectively and septal and lateral e’ were 4.2±1.0 and 5.2±0.9 cm/s, respectively. On univariate analysis EF was correlated with GLS (r=-0.48) but not with s’, MASE or e’ (p>0.05 for all). However, both s’ and MASE became positive correlates of EF in combination with LVEDL, which was a significant inverse correlate of EF (p<0.05 for all). s’ was modestly correlated with MASE (r2 = 0.37), but the prediction of s’ was improved in a multivariate model with the addition of heart rate to MASE (r2 =0.52). e’ was correlated with s’ (r2=0.09), but was more closely correlated with MASE (r2=0.18). On multivariate analysis, GLS was inversely correlated with MASE and positively correlated with LVEDL and BMI (r2=0.38, p<0.01 for all). In conclusion, in subjects with low e‘, GLS is more closely related to MASE than to s’ and is independently related to MASE, LVEDL and BMI.

Extent of Left Ventricular Hypertrophy Is Related to Interatrial Conduction Delay in Hypertensive Patients

The aim of this study was to investigate the relationship between left ventricular mass (LVM) and interatrial conduction delay (CD) measured by tissue Doppler echocardiography. In enrolled 66 hypertensive patients, positive correlation between interatrial CD and LVM index (r = 0.32) was detected. Meanwhile, intra-atrial CD was correlated to early diastolic tissue Doppler mitral annular velocity measured from septum (r = 0.34), tricuspid annular velocity (r = 0.29), and left atrial volume index (r = 0.26). By using stepwise linear regression analysis, LVM index was determined as an independent predictor of interatrial CD.

Assessment of ST‐Elevation Myocardial Infarction–Related Diastolic Dysfunction with Compensatory Rise in Left Atrial Ejection Force

It is well known that patients with ST-elevation myocardial infarction (STEMI) show both systolic and diastolic left ventricular dysfunction. The aim of this study was to assess post-myocardial infarction diastolic dysfunction using left atrial ejection force (LAEF) in patients treated with primary percutaneous coronary intervention (PCI). We enrolled 58 patients presenting with STEMI who were treated with primary PCI and 23 healthy subjects as a control group. A detailed transthoracic echocardiogram, including mitral flow velocities, tissue Doppler mitral annular velocities, and left atrial (LA) phasic volumes, was performed in both groups. We also measured the level of B-type natriuretic peptide (BNP). LAEF was calculated using the formula: 0.5×P×Mitral orifice area×(Peak A velocity)(2) . Correlations between variables were studied using "Pearson and Spearman's rho" test. In the test group, we found that the level of BNP in the plasma, E/E' ratio, and the LA volume measurements were higher than that of the control group, and those differences were statistically significant. LAEF was increased in patients with myocardial infarction (MI); moderately correlated to BNP (r=0.383 and P=0.001) and E/E' (r=0.473 and P=0.001), and strongly correlated to A-wave velocity (r=0.731 and P=0.001). LAEF was also negatively correlated to E/A ratio (r=-0.419 and P=0.001) and LVEF (r=-0.339 and P=0.003). Impaired diastolic function in STEMI affects LA and increased LAEF is one of its manifestations. LAEF may also have diagnostic importance in diastolic dysfunction, but these findings should be confirmed by further studies.

Transmitral Flow Patterns and the Presence of Chronic Kidney Disease Provide Independent and Incremental Prognostic Information in Patients with Heart Failure and Systolic Dysfunction

Transmitral flow patterns derived from Doppler echocardiography carry prognostic information in patients with chronic heart failure and systolic dysfunction. In such patients, chronic kidney disease (CKD) defined as a reduction in estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) is frequent, but its prognostic impact relative to that of transmitral flow patterns is unknown. This prospective study enrolled 292 patients with stable chronic heart failure and systolic dysfunction (mean ejection fraction 30 +/- 10), of whom 148 had CKD. Echocardiographic measurements comprised left ventricular dimensions/volumes, ejection fraction, the ratio of early (E) to late (A) transmitral flow velocity, deceleration time, and tissue Doppler mitral annular velocities. The mitral filling pattern (FP) was classified as either restrictive FP (RFP) or non-RFP. A cardiac event (cardiac death or urgent cardiac transplantation) was defined as combined study end point. During a follow-up of 497 +/- 373 days, 45 patients had a cardiac event (cardiac death, n = 42; urgent cardiac transplantation, n = 3). On multivariate Cox analysis including clinical and echocardiographic variables, independent prognostic predictors were RFP (hazard ratio: 2.77, 95% confidence interval 1.28-6.09), CKD (hazard ratio: 2.79, 95% confidence interval 1.24-6.28), and left atrial diameter. In patients with RFP, the prognosis was markedly worse in the presence of CKD as compared with the absence (event-free survival of 23% vs 83%, P = .03). Similarly, in patients with non-RFP, outcome was worse in the presence of CKD (event-free survival of 71% vs 88%, P = .003). In patients with chronic heart failure and systolic dysfunction, the presence of CKD adds incremental value to transmitral flow patterns in determining the prognosis.

Chronic kidney disease in patients with chronic heart failure — Impact on intracardiac conduction, diastolic function and prognosis

Background In patients with chronic heart failure (CHF), chronic kidney disease (CKD) is associated with increased morbidity and mortality, but contributing mechanisms are not well defined. This study tested the impact of CKD on intracardiac conduction, diastolic function and prognosis in patients with underlying CHF. Methods We prospectively enrolled 269 patients with stable CHF, of whom 135 had CKD (estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m 2). Echo measurements comprised left ventricular dimensions/volumes, ejection fraction, mitral E/ A-ratio, deceleration time and tissue Doppler mitral annular velocities ( S′, E′, A′). PQ and QRS intervals were derived from the 12-lead ECG. A cardiac event (cardiac death or urgent cardiac transplantation) was defined as combined study end point. Results Patients with CKD had longer PQ and QRS intervals, and were in a poorer NYHA functional class as compared to patients without CKD. In patients with CKD, the mitral annular E′ velocity was lower, the mitral E/ E′-ratio was higher and a restrictive mitral filling pattern was more frequent. By linear regression analysis, PQ and QRS intervals and the mitral E/ E′-ratio were inversely related to the eGFR. During a follow-up of 507 ± 375 days, 39 patients suffered a cardiac event. In CKD patients, outcome was markedly poorer as compared to those without CKD (event-free survival rate 51% vs. 87% in those without KD, p = 0.001) Conclusions In patients with CHF, CKD is associated with impaired intracardiac conduction and progressive diastolic dysfunction. Both mechanisms may contribute to increased morbidity and mortality of such patients.

Electrocardiography and Doppler echocardiography for risk stratification in patients with chronic heart failure: Incremental prognostic value of QRS duration and a restrictive mitral filling pattern

This prospective study tested whether Doppler echocardiographic variables add incremental value to QRS duration in determining the prognosis of patients with chronic heart failure (CHF) and systolic dysfunction. Diastolic dysfunction frequently is observed in patients with CHF, but its prognostic impact relative to that of QRS duration is unknown. A total of 193 patients with CHF and an ejection fraction <45% were enrolled prospectively. Echo measurements included left ventricular dimensions/volumes, ejection fraction, mitral early/late diastolic velocity ratio, deceleration time, and tissue Doppler mitral annular velocities. The mitral filling pattern was classified as either restrictive (RFP) or nonrestrictive. A cardiac event (cardiac death or urgent cardiac transplantation) was defined as combined study end point. During a follow-up of 385 +/- 270 days, 24 patients suffered an event (cardiac death, n = 21; urgent transplantation, n = 3). The RFP, QRS duration, left ventricular systolic diameter, and mitral annular early diastolic velocity were independent predictors of an event. In patients with QRS duration >144 ms, the outcome was markedly poorer in the presence of RFPs as compared with their absence. Similarly, despite a QRS duration <or =144 ms, the outcome was worse in the presence of a RFP. A risk-stratification model based on the three strongest independent predictors separated groups into those with good prognosis and those with high, intermediate, and low event-free survival rates. In subjects with CHF and systolic dysfunction, transmitral flow patterns add incremental value to QRS duration in determining the prognosis.

Hypertrophic Cardiomyopathy

ypertrophic cardiomyopathy (HCM) is a fascinatingdisease that has intrigued and challenged cardiolo-gists for decades. Initially a diagnosis made bymaster clinicians adept at translating bedside dynamic aus-cultation into hemodynamic pathophysiology, HCM contin-ues to challenge the frontiers of diagnosis and technology.The development of 2D and Doppler echocardiography pro-vided the greatest increment in understanding the complexityof HCM. While clinicians at large became skilled at thebedside detection of dynamic left ventricular outflow obstruc-tion, echocardiography revealed that many more patients hadunexplained left ventricular hypertrophy (LVH) consistentwith HCM but without evidence of obstruction. In fact, thenonobstructive, “silent” forms are more frequent than theobstructive, “noisy” variants. The pattern and severity ofLVH are now appreciated as heterogeneous and diastolicdysfunction as highly prevalent.