Transmitral Flow Pattern Research Articles

PR Interval as a Novel Therapeutic Target of Ivabradine Therapy-Prognostic Impact of Ivabradine-Induced PR Prolongation in Heart Failure Patients.

Ivabradine reduces heart rate by inhibiting the "funny current" expressed on the sinoatrial node and improves mortality and morbidity in patients with systolic heart failure and sinus tachycardia. The funny current is known to be expressed also on the atrioventricular node according to experimental studies. However, the impact of ivabradine on PR interval remained unknown. Patients with a left ventricular ejection fraction of less than 50% who received 1 month of ivabradine were screened. Electrocardiographic and echocardiographic data, particularly concerning heart rate, the PR interval, and trans-mitral flow pattern, were collected at baseline and 1-month follow-up. The primary endpoint was defined as the composite of cardiovascular death and hospital readmission for worsening heart failure following ivabradine administration. In the cohort of 29 enrolled patients (median age: 66 years, 62% male), the median baseline heart rate was 86 beats per minute and the median PR interval was 168 milliseconds. Following ivabradine administration, a significant decrease of 20 beats per minute in the heart rate and a significant increase of 24 milliseconds in the PR interval were observed. The truncated interval of the A-wave, detected in the trans-mitral flow, consistently demonstrated a negative correlation with the PR interval both before and after the administration of ivabradine. During a median of 1.8 years of follow-up, six patients reached the primary endpoint. A combination of heart rate reduction and PR prolongation following ivabradine administration, both of which were independent factors associated with the primary endpoint (p < 0.05 for both), was associated with greater freedom from the primary endpoint compared with either/neither of them (p = 0.002). Ivabradine seems to prolong PR interval, which is a novel surrogate marker of favorable clinical outcomes in patients with systolic heart failure. This effect may be associated with the dynamics of the trans-mitral flow pattern, in conjunction with heart rate and the PR interval. Clinical implications of PR interval-guided ivabradine therapy remains the future concern.

The Feline Cardiomyopathies: 3. Cardiomyopathies other than HCM

Practical relevance:Although feline hypertrophic cardiomyopathy (HCM) occurs more commonly, dilated cardiomyopathy (DCM), restrictive cardiomyopathy (RCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), left ventricular noncompaction (LVNC) and cardiomyopathy – nonspecific phenotype (NCM; formerly unclassified cardiomyopathy) are all recognized in domestic cats.Patient group:Any adult domestic cat, of either sex and of any breed, can be affected.Diagnostics:The non-HCM cardiomyopathies are rarely suspected in subclinically affected cats, so most are first identified when a cat presents with signs of heart failure or systemic thromboembolic disease. The definitive clinical confirmatory test for these other feline cardiomyopathies is echocardiography.Key findings:‘Cardiomyopathy – nonspecific phenotype’ is a catch-all term that groups hearts with myocardial changes that either do not meet the criteria for any one type of cardiomyopathy (HCM, RCM, DCM, ARVC, LVNC) or meet the echocardiography criteria for more than one type. RCM is characterized by diastolic dysfunction due to fibrosis that results in a restrictive transmitral flow pattern on Doppler echocardiography and usually marked left or biatrial enlargement. DCM is characterized by decreased myocardial contractility and is rare in cats. When it occurs, it is seldom due to taurine deficiency. However, since taurine-deficient DCM is usually reversible, a diet history should be obtained, whole blood and plasma taurine levels should be measured and taurine should be supplemented in the diet if the diet is not commercially manufactured. ARVC should be suspected in adult cats with severe right heart enlargement and right heart failure (ascites and/or pleural effusion), especially if arrhythmia is present. Feline LVNC is rare; its significance continues to be explored. Treatment of the consequences of these cardiomyopathies (management of heart failure, thromboprophylaxis, treatment of systemic arterial thromboembolism) is the same as for HCM.Conclusions:While these other cardiomyopathies are less prevalent than HCM in cats, their clinical and radiographic presentation is often indistinguishable from HCM. Echocardiography is usually the only ante-mortem method to determine which type of cardiomyopathy is present. However, since treatment and prognosis are often similar for the feline cardiomyopathies, distinguishing among the cardiomyopathies is often not essential for determining appropriate therapy.Areas of uncertainty:The feline cardiomyopathies do not always fit into one distinct category. Interrelationships among cardiomyopathies in cats may exist and understanding these relationships in the future might provide critical insights regarding treatment and prognosis.

Aortic diameter, pulse wave velocity, central aortic pulse pressure, left ventricular parameters, and diastolic dysfunction in patients with aortic aneurysm

Abstract Background The enlargement of aortic aneurysm can alters pulse wave propagation and reflection, which may influence to left ventricular (LV) afterload changes. The relevance of pulse wave velocity (PWV) and central blood pressure depending on the locus of the aneurysm for LV structure and diastolic function (DF) are not clearly unknown. Purpose Assess the relationship between central pulse pressure (CPP), PWV and LV structure and DF in patients with ascending aortic aneurysm (AA) and abdominal aortic aneurysm (AAA). Methods 121 patients (95 male, 63±12 years) with aortic aneurysms and preserved LV systolic function were enrolled before aortic repair. 51 patients (37 male, 54±13 years) had AA and 70 patients (58 male, 69±7 years) had AAA. CPP and PWV were measured using applanation tonometry. A echocardiographic exam was performed with a Vivid 7 GE (USA). LV mass index (LVMI) and relative wall thickness (RWT) were calculated according to standard formulas. LV filling pressure (E/Em) was estimated by Doppler-derived ratio of mitral inflow velocity (E) to septal (Em) by tissue Doppler. Transmitral flow patterns (E/A ratio of E to late (A) ventricular filling velocities) were measured with the pulsed doppler method. Results Concentric LV hypertrophy (LVH) was observed in 51 (42%), eccentric LVH – in 35 (29%) patients. CPP was positively related with LVMI (r=0.362, P=0.001), but PWV was inversely associated with LVMI (r=−0.244, P=0.029). CPP was not associated with RWT (P≥0.5), whereas PWV was positively related (r=0.223, P=0.004). PWV decreased with increasing aortic diameter in AA and AAA (r=−0.360, P=0.029 and r=−0.315, P=0.019, respectively). 12 (23%) patients with AA and 36 (56%) patients with AAA had grade I diastolic dysfunction, 20 (40%) patients with AA and 12 (18%) patients with AAA had grade II diastolic dysfunction (P&amp;lt;0.001). Consequently, the E/A ratio was higher in patients with AA than in patients with AAA (1.21±0.39 vs 0.83±0.33; P=0.007). CPP and PWV was inversely associated with LV DF (E/A: r=−0.352 and −0.238; E/Em: r=−0.292 and −0.279, respectively; both P&amp;lt;0.05). E/A and E/Em increased with the expansion of the maximum aortic diameter at the level of the AA and AAA (E/A: r=0.612 and 0.416; E/Em: r=0.719 and 0.339, respectively; both P&amp;lt;0.005). RWT and LVMI were correlated with the aortic diameter at the level of the AA (r=−0.439, P=0.008 and r=0.286, P=0.05, respectively), but bore no relation with the aortic diameter at the level of the AAA. Conclusions In patients with aortic aneurysm CPP and PWV were conjointly but differently related to LV structure. Eccentric LV hypertrophy was accompanied by a significant decrease of PWV. Reduced PWV and decreased CPP exhibited association with more severe LV diastolic dysfunction, possibly due to the apparent effect of increased aortic aneurysm diameter. LV DF was severely reduced in the patients with AA compared by patients with AAA. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Almazov National Medical Research Centre

Factors contributing to energy loss in left ventricle during diastolic and systolic phases in elderly patients.

The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL. A single-center retrospective study was performed on elderly hypertensive outpatients (≥65 years) who underwent echocardiography (N = 105). EL in the LV was measured using a vector flow mapping system, and factors affecting peak EL during the early-diastolic phase (ED-EL), late-diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated. Mean age was 79.9 ± 6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1 ± 46.7, 75.6 ± 60.2, and 40.4 ± 40.2 mJ/N/s. In a stepwise regression analysis, the E/e'(lateral) (unstandardized B = 0.005, 95%CI -0.03 to 0.007, standardized β = 0.434, P < .001) was identified as factors affecting ED-EL. The factors affecting LD-EL were E/A ratio (B = -0.122, 95%CI -0.176 to -0.068, β = -0.470, P < .001) and time velocity integral (TVI) in LVOT (unstandardized B = 0.002, 95%CI 0.000 to 0.004, β = 0.247, P = .021). The factors influencing Sys-EL were TVI in LVOT (B = 0.002, 95%CI 0.001 to 0.004, β = 0.390, P < .001), E/A ratio (B = -0.054, 95%CI -0.093 to -0.015, β = -0.258, P = .008), left ventricular outflow tract (LVOT) diameter (B = -0.006, 95%CI -0.010 to -0.002, β = -0.307, P = .006), and left ventricular mass index (B = 0.000, 95%CI 0.000 to 0.001, β = 0.208, P = .039). Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL both during late-diastolic phase and systolic phase was affected by systolic blood flow in LVOT and LV transmitral flow pattern.

Pirfenidone is Associated with Decreased Indexed End Diastolic and Systolic Volumes in Patients with HFpEF and a Known History of Idiopathic Pulmonary Fibrosis

Background To date, there remains to be a lack of effective treatment modalities for HFpEF, which accounts for approximately 50% of all cases of congestive heart failure. Pirfenidone is a novel anti-fibrotic agent that has been shown to improve pulmonary function in patients with Idiopathic Pulmonary Fibrosis. In pre-clinical studies, pirfenidone has been implicated in decreasing myocardial fibrosis and diastolic dysfunction (Kuwahara et al, Circulation 2002). The effects of this medication on markers of LV function and structure in humans with a history of IPF and HFpEF has not been studied. Hypothesis We hypothesize that patients taking pirfenidone will have favorable changes in echocardiographic parameters of LV function and structure. Methodology We performed a retrospective review of 24 patients with a history of HFpEF and IPF being treated with pirfenidone. All patients had pre and post treatment echocardiograms. Changes in parameters of LV structure (indexed LV mass, end diastolic and end systolic volumes), diastolic function (indexed left atrial volume, trans-mitral Doppler flow patterns, tissue Doppler indices), systolic function (EF) and global LV strain were compared before and after pirfenidone administration. Results mean age of patients involved was 70±6.8 years and patients were predominantly males(76%). 34% patients had a history of CAD, 62% HTN, 16% Atrial fibrillation, 61% hyperlipidemia, 23% diabetes, 25% CKD and 46% obesity. 88% of patients had stage 1 diastolic dysfunction at baseline and 12% with stage 2 diastolic dysfunction. Mean NT pro BNP was 2287±3444 pg/ml . Post pirfenidone treatment, there was a significant reduction in indexed LV end diastolic(-11.9±1.1ml/m2) and end systolic (-6.2±2.3ml/m2) volumes. No significant changes were noted in other parameters. Conclusion Treatment with pirfenidone was associated with decreases in indexed LV end diastolic and end systolic volumes in patients with HFpEF and a known history of IPF. However, contrary to the rest of the hypothesis, no improvements were noted in markers of LV diastolic, systolic function and strain. Our study was retrospective in nature and limited by its small sample size.

Role of Flow Propagation Velocity Across Mitral Valve in the Assessment of Diastolic Dysfunction and Prognostication in Acute Myocardial Infarction

Background: The importance of left ventricular (LV) systolic dysfunction as a predictor of mortality and morbidity after acute myocardial infarction (MI) is well known. In MI, Doppler echocardiography can be used to determine the LV diastolic function, and a restrictive transmitral flow pattern has been related to the development of congestive heart failure and increased mortality. In patients with various etiologies of LV systolic dysfunction, restrictive filling has also proven to be an independent predictor of adverse outcome. Materials and Methods: 130 patients who presented with diagnosis of acute MI were included. Echocardiography was performed within 24 hours of arrival to the coronary care unit. Most widely used approach for measuring mitral-to-apical flow was used for velocity propagation. Based on the ratio E/Vp, patients divided into two groups with E/Vp &lt;1.5 and E/Vp &gt;1.5. Patients were followed up subsequently. Results: In the study population, the average age of patients was 59 ± 11.6 years. There were 105 male (80.77%) and 25 female patients (19.23%). On evaluation of risk factors, 69 patients (53.08%) were hypertensive, 71 patients (54.62%) were diabetic, 7 patients (5.38%) were smokers, and 43 patients (33.08%) had dyslipidemia. In patients with E/Vp &lt;1.5, 31 patients (73.81%) had Grade I diastolic dysfunction (DD) and 10 patients (23.81%) had Grade II DD. One patient (2.38%) had Grade III DD. In patients with E/Vp &gt;1.5, 20 patients (22.73%) had Grade I DD, 52 patients (59.09%) had Grade II DD and 16 patients (18.18%) had Grade III DD. Conclusion: In this echocardiographic study of 130 patients with MI E/Vp measured with color M mode is easily obtainable and this E/Vp is a strong predictor of heart failure and mortality. The ratio of peak E wave velocity to flow propagation velocity can be used with other diastolic function variables in predicting outcome. Furthermore, these Doppler variables may be used as simple tools to rapidly risk stratify patients with acute MI.

P4582The role of TDI diastolic measurements for prognostic prediction early and late after surgical ventricular reconstruction

Abstract Aim 1. To evaluate the impact of preoperative left ventricular (LV) diastolic performance on early and late outcomes in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) and surgical ventricular reconstruction (SVR). 2. To investigate LV diastolic function dynamics according to the results of tissue Doppler imaging (TDI) in these patients. 3. To assess the echographic predictors for persistence of the restrictive LV diastolic filling pattern (LVDFP) late after CABG and SVR. Material and method Prospective study on 157 pts with LV systolic dysfunction (LVEF &lt;30%) who underwent CABG and SVR, evaluated including TDI preoperatively, early (&lt;1 month), medium (3 and 12 months) and late postoperatively (mean 4,8 years). Statistical analysis used SYSTAT and SPSS. The primary outcome was the time to death from any cause or hospitalization for cardiac causes. Results 1. The preoperative restrictive LVDFP was an independent and predominant predictor for increasing the early and late postoperative risk of cardiovascular events (p=0.001). At 5 years postoperatively, cardiovascular event-free survival was significantly higher in pts with nonrestrictive LVDFP (75%) compared with restrictive LVDFP (55,74%) (p&lt;0.0001). 2. Conventional transmitral diastolic Doppler indices before and after CABG +SVR remained unchanged. TDI showed significant improvement before and in 3 and 12months postoperatively of both LV systolic (S: 6.1±0.9, 7.5±1.1 and 7.3±1.2 cm/sec, p&lt;0.01) and diastolic function (e': 7.2±1.8, 8.3±1.4 and 8.8±1.5 cm/sec; E/e' ratio: 17.8±2.1, 13.1±1.7 and 11.3±1.8; Vp 3.2±0.55, 2.4±0.28 and 1.9±0.26, p&lt;0.01). 3. The evolution of LVEF, LV end-diastolic volume (LVEDV) and mitral regurgitation (MR) severity was different in nonrestrictive group (early and late postoperatively these variables improved) compared with restrictive group (late after surgery the variables deteriorated: LVEF from 27±8% to 22±6%, LVEDV from 181±49 to 234±63 cm3 and MR degree from 0.9±0.6 to 1.8±0.7; p&lt;0.005). 4. Regression analysis identified as predictors for persistence of a restrictive LVDFP late after surgery: E/E' ratio &gt;14 (RR=19.3), LA dimension index &gt;30 mm/m2 (RR=9.2), LVEDV &gt;200 cm3 (RR=9.6), severe PHT (RR=11.4), 2 degree MR (RR=14.8). Conclusions 1. TDI evaluation demonstrate significant improvement of LV systolic diastolic function in CABG + SVR pts, regardless of transmitral flow pattern. TDI is more sensitive and preload independent method of LV function evaluation. 2. The preoperative LVDFP has an independent and incremental prognostic value in CABG+SVR pts, strongly related to higher mortality with aggravation of LV systolic function, MR severity or LV remodeling. This might be attributable to deterioration of diastolic function induced by SVR. 3. Late after CABG+SVR the restrictive LVDFP persistence was predicted by: E/E' ratio &gt;14, LA dimension index &gt;30 mm/m2, LVEDV &gt;200 cm3, severe PHT and 2 degree MR.

Detection and evaluation of left ventricular diastolic dysfunction in asymptomatic type 2 diabetic patients by conventional and tissue doppler imaging

Background: Diabetic cardiomyopathy is characterised predominantly by diastolic dysfunction. While the traditional echocardiography provides only semiquantitative assessment of diastolic dysfunction, tissue Doppler imaging proved to be an effective technique for the quantification of subclinical diastolic dysfunction.Methods: The current cross-sectional study was conducted in out-patient department of General Medicine, Tagore Medical College and Hospital for a period of 6 months. The study population comprised of 100 patients with type 2 diabetes mellitus including 39 male and 61 females. Echocardiography (using Siemens – Acuson NX3 Elite - system with TDI technology) was performed to all subjects in the left lateral position and 2D, M- mode, Doppler techniques were used. The early E wave corresponding to early ventricular filling and A wave which reflect a trial contraction were typically measured to assess the transmitral flow pattern. Systolic S' (Sa), early diastolic E (Ea) and the late diastolic velocities A' (Aa) were measured by tissue Doppler imaging.Results: The E/A ratio ranged from 0.5 to 2 and E/Ea ratio ranged from 1.59 to 14.67. Around 23 patients and 54 patients were abnormal by E/A and E/Ea ratios respectively. Around 29 patients showed grade II diastolic dysfunction by tissue Doppler imagingConclusions: Prompt diagnosis of diastolic dysfunction help us to identify high risk patients who are likely to be benefitted by early therapeutic intervention. Tissue Doppler imaging may be a better tool in the identification of diastolic dysfunction especially grade II in comparison with the conventional echocardiography.

Responses to Pirfenidone Treatment in Patients with Idiopathic Pulmonary Fibrosis is Not Associated with Changes in Echocardiographic Parameters of Left Ventricular Structure and Function

Background Pirfenidone, an FDA-approved novel anti-fibrotic agent used in the treatment of idiopathic pulmonary fibrosis (IPF), has been implicated in mitigating myocardial fibrosis, systolic and diastolic dysfunction in animal models (Kuwahara et al, Circulation 2002). However to date, the effect of Pirfenidone on left ventricular (LV) structure and function in humans with IPF has not been studied. Hypothesis We hypothesize that changes in echocardiographic parameters of LV structure and function would be more favorable in responders compared to non-responders of pirfenidone in patients with IPF. Methods We performed a retrospective review of 27 consecutive patients with IPF on pirfenidone between 2014-2018 with serial baseline and follow up echocardiograms and pulmonary function testing. Treatment failure (non-response) was defined as an absolute decline in forced vital capacity (FVC) of more than 10% whilst being on the medication. Comprehensive echocardiographic data extraction and analysis was performed in all patients. Changes in parameters of LV structure (LV mass, interventricular septal and posterior wall thickness, indexed end systolic and diastolic volumes), systolic function (LVEF), diastolic function (Indexed left atrial volume, trans-mitral Doppler flow patterns, tissue Doppler indices) and global LV longitudinal strain were compared between responders and non-responders. Results In our study cohort, 18 responders and 9 non-responders were identified. Responders were significantly older than non-responders, yet sex, history of CAD, hypertension, diabetes, atrial fibrillation, CKD and cardiac medication use were not significantly different. Baseline echocardiographic parameters were comparable, except for septal e/e’, which was higher in responders (11.68 vs 10.1; p Conclusion In contrary to our hypothesis, we observed that response to pirfenidone therapy in patients with IPF did not associate with echocardiographic changes of left ventricle structure and function.

A clinical application of preload stress echocardiography for predicting future hemodynamic worsening in patients with early-stage heart failure.

To improve the prognosis of patients with heart failure, risk stratification in their early stage is important. We assessed whether the change in transmitral flow (TMF) velocity pattern during preload augmentation can predict future hemodynamic worsening in early-stage heart failure patients with impaired relaxation TMF pattern. We designed a prospective cohort study that included 155 consecutive patients with impaired relaxation (IR) pattern at rest. Preload stress echocardiography was achieved using leg-positive pressure (LPP), and changes in TMF pattern during the LPP was observed during baseline echocardiographic examination. The patients whose TMF pattern developed to pseudonormal (PN) pattern throughout the study period were classified into the change to PN group, and patients whose TMF pattern stayed in IR pattern were classified into the stay in IR group. The median follow-up period was 17months. The average age was 68±11years old, and 97 patients (63%) were male. Among 155 patients, 27 were classified into the change to PN group. A Cox proportional hazard analysis confirmed that the change in the peak atrial systolic TMF velocity during the LPP (ΔA, hazard ratio=0.58 per 1SD; 95% CI=0.39-0.88, P=0.010) was the powerful independent predictor of change into PN pattern. Kaplan-Meier analysis revealed that the patients with ΔA≤-7cm/s had more likely to develop into PN pattern than patients with ΔA>-7cm/s (P=0.001). Evaluation of a response in TMF during the LPP might provide an incremental diagnostic value to detect future overt heart failure in patients with early-stage heart failure.

Transmitral Doppler Flow Pattern in Left Atrial Myxoma.

Transmitral Doppler Flow Pattern in Left Atrial Myxoma.

P1-1 - Outpatient Carpertide Infusion Therapy for a Patient With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Syndrome (MELAS)

A case was a 46 year-old woman. She had short stature, juvenile diabetes, hearing loss, LV hypertrophy and diagnosed as MELAS at age of 39 year-old. Echocardiography showed LVDd of 51 mm; LVDs of 39 mm; IVST of 14 mm; LVPWT of 14 mm; EF of 31%. Despites oral administration of furosemide 40 mg, tolvaptan 3.75 mg, eplerenone 25 mg, perindopril 2 mg, carvedilol 3.75 mg, pimobendan 2.5 mg, she repeated hospitalization for heart failure 5–6 times a year. Since carperitide was very useful as inpatient treatment, we tried intermittent carperitide infusion therapy (starting with 0.033γ and increasing to 0.1γ every 30 minutes; 4 hours administration) in outpatient setting every 1 or 2 weeks. After 4 hours infusion therapy, lung congestion was disappeared and also indicators of transmitral flow pattern and tricuspid regurgitation pressure gradient were improved. The introduction of this therapy reduced hospitalization once in six months. In addition, total healthcare costs per 6 months decreased to less than half. Conclusion: Intermittent carperitide infusion therapy for a patient with MELAS in outpatient setting reduced hospitalization and total healthcare costs.

The usefulness of combined assessment of E/E' ratio and transmitral flow pattern to interpret cardiac condition.

High mitral inflow early (E) velocity to tissue Doppler E' ratio (E/E') and an E to late diastolic filling velocity ratio (E/A) are used to evaluate left ventricular (LV) diastolic function and filling pressure, but the usefulness of combined assessment of E/E' and E/A is not fully understood. Methods: We retrospectively analyzed 1,266 patients who underwent echocardiography to assess cardiac function. Patients were grouped based on the values of E/E' (low E/E'<15, high E/E'≥15) and E/A (low E/A≤0.8, high E/A>0.8). Results: High E/E' with both high and low E/A groups showed lower LV ejection fraction and higher LV mass index compared to low E/E' with both high and low E/A groups. High E/E' with both high and low E/A groups showed slower E' velocity and larger left atrial volume index compared to low E/E' with both high and low E/A groups, but high E/E' with low E/A group exhibited smaller left atrial volume index and higher pulmonary venous systolic to diastolic peak velocity ratio compared to high E/E' with high E/A group. Moreover, high E/E' with low E/A group displayed lower tricuspid regurgitant pressure gradient than the high E/E' with high E/A group. Conclusion: Even in the situation of high E/E', low E/A condition indicated lower LV filling pressure and controlled fluid retention.

Left ventricular diastolic dysfunction in patients with ST-elevation myocardial infarction following early and late reperfusion by coronary intervention

BackgroundThis study prospectively assessed the left ventricular (LV) diastolic function changes in patients with ST-elevation myocardial infarction (STEMI) and determined if the early revascularization of the infarct-related coronary artery in acute phase achieve a better recovery of diastolic function than late recanalization. MethodsForty-five consecutive patients (61.20±11.37years, 8 females) presenting with STEMI and treated with PCI were prospectively enrolled in this study. The important inclusion criteria were first acute coronary syndrome episode and LV ejection fraction exceeded 45%. The patients were divided to two different groups by total ischemia time (TIT): early reperfusion (TIT<6h) and late reperfusion group (TIT≥6h). Transthoracic echocardiography were performed within the first week after PCI, and data were compared between groups. Evaluation of diastolic function was based on integrated assessment of trans-mitral Doppler flow pattern, tissue Doppler, and color M-mode ECT. ResultsA normal diastolic filling pattern was seen in only 9 patients, and the other 80% patients had abnormal filling patterns: 16 impaired relaxation, 14 pseudonormal, and 6 restrictive filling patterns. The e′septal velocity was lower in early reperfusion group compared to late reperfusion group (5.52±1.67cm/s vs 7.11±2.14cm/s, P<0.05), but no statistical difference was found in E/e′ average (11.99±4.30 vs 9.85±3.47, P>0.05). There was also no statistical difference for left atrial volume index and mitral annulus propagation velocity between groups. ConclusionsLV diastolic dysfunction was present in most of acute MI patients even after successful PCI. It seemed STEMI patients receiving early myocardial reperfusion had no better diastolic functions compared with late-reperfused patients within the acute phase.

Effects of 0.5% Timolol Maleate Ophthalmic Solution on Heart Rate and Selected Echocardiographic Indices in Apparently Healthy Cats.

BackgroundEchocardiographic assessment of diastolic function is challenging in cats, partially because of transmitral flow pattern fusion associated with high heart rates. With heart rate (HR) reduction, transmitral flow waveforms separate, allowing identification of diastolic dysfunction. Timolol, an ophthalmic, nonselective beta‐blocker used in glaucoma is safe and transiently decreases HR in clinical trials.HypothesisAdministration of timolol ophthalmic solution decreases HR and facilitates echocardiographic assessment of diastolic function in cats without inducing clinically relevant adverse effects.AnimalsTwenty‐five apparently healthy cats.MethodsElectrocardiograms and echocardiograms including transmitral flow patterns were evaluated before and 20 minutes after ocular administration of 1 drop of timolol 0.5% solution. Twenty cats underwent treatment with timolol, and 5 different cats served as untreated controls to evaluate the effects of acclimation to the hospital environment on HR.ResultsAcclimation to the hospital had no effect on HR in control cats. After timolol administration, a significant median HR reduction of 25 bpm was observed (P < .0001). Timolol had no effect on E/A ratio in cats without E/A fusion (7/20, P = .44). Of the 13 cats with E and A waves that were fused before timolol application, separation of these waves was identified in 8 cats (62%) after timolol treatment. No bradyarrhythmias were noted after timolol administration, but 2 cats had first‐degree atrioventricular block. Timolol resulted in resolution of dynamic outflow tract obstruction in 6 of 6 cats.Conclusions and clinical importanceOcular administration of timolol safely decreases HR in cats and could facilitate assessment of diastolic function.

Abstract 18996: Impact of Infarct Size on Left Ventricular Diastolic Function Following Acute Myocardial Infarction

Introduction: Severe left ventricular diastolic dysfunction is associated with worse prognosis after acute myocardial infarction (MI). Twenty percent of patients have a restrictive filling pattern (RFP) following MI, and this is associated with a fourfold increase in mortality. The determinants of diastolic function in this setting are not well defined. Aim: We sought to determine the correlation between enzymatic infarct size and RFP in patients with a first ever MI. We hypothesized that a larger infarct size would result in greater impairment of left ventricular diastolic function. Methods: Data analysis was performed on consecutive patients admitted with first ever non-ST elevation MI (NSTEMI) or ST-elevation MI (STEMI) to a single large tertiary referral hospital from January 2013 to December 2014. All patients underwent coronary angiography during the index admission. Infarct size was determined by peak troponin I. Doppler transmitral flow pattern was obtained from the initial transthoracic echocardiogram performed within 48 hours of admission. RFP was defined as: E/A ratio &gt;2.0 and/or E-wave deceleration time &lt;160ms (American Society of Echocardiography Guidelines 2009). Results: Data were available on 645 consecutive patients who underwent coronary angiography for MI. We excluded 160 patients with a previous MI. Of the remaining 485 patients (mean age 62±13 years; mean left ventricular ejection fraction (LVEF) 53±12%), there were 338 NSTEMIs (70%) and 147 STEMIs (30%). PCI was performed in 360 (74%) patients (single vessel (82%), ≥2 vessels (18%)); coronary artery bypass surgery in 58 (13%); and medical management in 67 (13%). Sixty-nine patients (14.4%) had RFP; 52% of these had a LVEF ≥45%. Peak troponin I levels were higher in the RFP group (31.8±30.9μg/L vs 16.8±25.2μg/L, p=&lt;0.001). On multivariate analysis, infarct size by peak troponin I (OR 1.02, 95%CI 1.00-1.03, p=0.026) and low LVEF (OR 0.95, 95%CI 0.91-0.99, p=0.015) were the only independent predictors of RFP. Conclusion: Infarct size was a major determinant of diastolic dysfunction following first ever MI. Whilst LV systolic dysfunction was strongly associated with impaired diastolic function, 52% of patients with severe diastolic dysfunction had relatively preserved LVEF.

Shunt Closure Improved the Transmitral Flow Pattern in a Patient with Chronic Heart and Renal Failure on Hemodialysis

Shunt Closure Improved the Transmitral Flow Pattern in a Patient with Chronic Heart and Renal Failure on Hemodialysis

Calcium desensitizer catechin reverses diastolic dysfunction in mice with restrictive cardiomyopathy

Diastolic dysfunction refers to an impaired relaxation and an abnormality in ventricular blood filling during diastole while systolic function is preserved. Cardiac myofibril hypersensitivity to Ca2+ is a major factor that causes impaired relaxation of myocardial cells. The present study investigates the effect of the green tea extract catechins on myofibril calcium desensitization and restoration of diastolic function in a restrictive cardiomyopathy (RCM) mouse model with cardiac troponin mutations. Wild type (WT) and RCM mice were treated daily with catechin (epigallocatechin-3-gallate, EGCg, 50mg/kg body weight) for 3months. Echocardiography and cell based assays were performed to measure cardiac structure and flow-related variables including chamber dimensions, fraction shortening, trans-mitral flow patterns in the experimental mice. In addition, myocyte contractility and calcium dynamics were measured in WT and RCM cardiomyocytes treated in vitro with 5μM EGCg. Our data indicated that RCM mice treated with EGCg showed an improved diastolic function while systolic function remained unchanged. At the cellular level, sarcomere relaxation and calcium decay were accelerated in RCM myocardial cells treated with EGCg. These results suggest that catechin is effective in reversing the impaired relaxation in RCM myocardial cells and rescuing the RCM mice with diastolic dysfunction.

Prognostic significance of persistent restrictive filling pattern after cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) may improve left ventricular (LV) diastolic dysfunction as well as systolic dysfunction. Diastolic dysfunction is a key for prognosis in patients with heart failure; therefore, we aimed to clarify the impact of CRT on diastolic function and prognosis. In 67 patients who underwent CRT, LV diastolic function was assessed by pulsed Doppler transmitral flow pattern at baseline and 1 week after CRT, and classified into restrictive filling pattern (RFP) and non-RFP groups. Volume responders were defined by reduction of LV end-systolic volume >15% at 6 months after CRT. The clinical endpoint comprised death from any cause or unplanned hospitalization for a major cardiovascular event (MACE). During the follow-up period (479 ± 252 days), 26 patients (38.8%) had reached the endpoint of MACE. In Cox proportional hazard analyses, RFP at 1 week after CRT was associated with the endpoints independently of age and New York Heart Association (NYHA) class IV at baseline. Thirty (44.8%) patients were identified as volume responders, who had better prognosis than non-responders. Patients were classified into 4 groups based on their filling pattern at 1 week after CRT and volume responses. The worst prognosis was observed in the RFP and non-responder group, and the best was observed in the non-RFP and responder group. For the remaining 2 groups with intermediate prognosis, the RFP and responder group showed poorer prognosis compared to the non-RFP and non-responder group. Persistent RFP after CRT may be a strong prognostic predictor, which should be treated with more intensive therapy to improve the prognosis of patients following CRT.

Abstract 11798: The Usefulness of Combined Assessment of E/e’ Ratio and Transmitral Flow Pattern to Interpret Cardiac Condition

Background: High mitral inflow E velocity to tissue Doppler e’ ratio (E/e’) is implicated as increased left ventricular (LV) filling pressure, but it is not always consistent with clinical findings. Early (E) and late (A) diastolic filling velocity ratio (E/A) is also used to evaluate LV diastolic function and filling pressure, but the usefulness of combined assessment of E/e’ and E/A is not fully understood. Methods: We retrospectively analyzed 1266 patients who underwent echocardiography to assess cardiac function between January 2013 to March 2014 in our hospital. The patients were grouped based on the values of E/e’ (low E/e’&lt;15, high E/e’≥15) and E/A (low E/A≤0.8, high E/A&gt;0.8). Results: First, we analyzed a role of E/A in the setting of high E/e’ condition. The low E/A with high E/e’ group (n=95) displayed lower tricuspid regurgitant pressure gradient (TRPG, 22 [16-28] mmHg vs. 29 [23-38] mmHg, P&lt;0.01) and smaller inferior vena cava (IVC) diameter (12 [10-15] mm vs. 14 [11-17] mm, P&lt;0.01) than the high E/A with high E/e’ group (n=136), suggesting that low E/A indicated controlled fluid retention even with high E/e’. We next investigated the role of E/e’ in the situation of low E/A state. Compared to the low E/A with low E/e’ group (n=584), the low E/A with high E/e’ group showed similar TRPG (22 [16-28] mmHg vs. 21 [17-26] mmHg, ns), similar IVC diameter (12 [10-15] mm vs. 12 [10-15] mm, ns), but larger LV end-diastolic diameter (48 [42-52] mm vs. 45 [40-50] mm, P&lt;0.01), larger left atrial volume (53 [38-67] ml vs. 41 [29-54] ml, P&lt;0.01), lower LV ejection fraction (59 [47-66]% vs. 63 [57-67]%, P&lt;0.01), and slower LV systolic velocity (5.9 [4.9-7.3] cm/s vs. 7.8 [6.5-9.5] cm/s, P&lt;0.01), indicating that high E/e’ was a predictor of LV remodeling and dysfunction in the situation of low E/A condition. Conclusions: The low E/A indicated controlled fluid retention regardless of E/e’ value. A high E/e’ reflected LV remodeling and dysfunction. Thus, we conclude that combined assessment of E/e’ and E/A is useful to interpret cardiac condition.