Transmitral Flow Velocity Curves Research Articles

Prognostic impact of mitral L-wave in patients with hypertrophic cardiomyopathy without risk factors for sudden cardiac death.

Hypertrophic cardiomyopathy (HCM) with severe diastolic dysfunction is a major cause of heart failure and sudden cardiac death (SCD) associated with lethal arrhythmia. Although various risk factors for cardiac events have been reported in HCM patients, previous studies have reported that some HCM patients exhibit either no risk or a low risk of SCD experienced cardiac events. The mid-diastolic transmitral flow velocity curve (mitral L-wave) is an echocardiographic index of left ventricular compliance, and it has been reported as one of the parameters of advanced diastolic dysfunction assessed noninvasively. However, little is known about the association between the mitral L-wave and long-term clinical outcomes in HCM patients without SCD risk factors. Between July 2005 and February 2016, 112 patients were diagnosed with HCM and 96 patients without risk factors were enrolled. After excluding 3 patients whom we could not detect L-wave more than once, 93 patients (mean age 57.7 ± 13.1years, 33 females) were divided into the following two groups, according to the presence or absence of the mitral L-wave: Group L (+) (with the mitral L-wave) and Group L (-) (without the mitral L-wave). The correlations between the mitral L-wave and rates of cardiac events were investigated. The mitral L-wave was present in 14 (15.1%) patients [Group L]. During the follow-up period [4.7 (2.9-7.5) years], patients experienced 7 cardiac events. Kaplan-Meier survival analysis showed that the event-free rate was significantly lower in Group L (+) than in Group L (-) (log-rank P = 0.002). Additionally, in multivariate analysis, L-wave positivity was identified as independent predictors of cardiac events. Existence of the mitral L-wave can predict cardiac events, even in HCM patients without SCD risk factors.

English

BACKGROUND: Several clinical studies have reported that 30% to 50% of patients with congestive heart failure have preserved left ventricular systolic function and isolated diastolic dysfunction. Detection of diastolic dysfunction is important factor in cardiac evaluation of hypertensives. MATERIAL AND METHODS: retrospective study carried out in Medicine department, SIMS, Shimoga for one year from Jan 2013 to Jan 2014. 50 patients who are hypertensive without any abnormality were studied general and systemic examination done, 2d echocardiography done in which transmitral flow velocity (E/A) and pulmonary venous A duration- mitral A duration (∆d) is measured. RESULT: 32% of subjects were newly diagnosed hypertensives in our study. 56% of cases had normal diastolic function as defined by E/A ratio (>1), 18% of cases in our study with normal E/A ratio were found to have pseudonormal pattern of diastolic function. LVDD of 62% is found in this study. CONCLUSION: The abnormal diastolic function as assessed by abnormal E/A ratio was seen in 44% of cases. Abnormal ∆d was found in 18% of cases out of 56% who had normal E/A ratio. These cases are said to have 'pseudonormal' pattern of diastolic function. The current study demonstrated that the presence of LV diastolic dysfunction in hypertensive patients is actually greater than previously reported by studies that analyzed transmitral flow velocity curves alone. To avoid overlooking patients with diastolic dysfunction, the combined analysis of transmitral and

Echocardiographic estimation of left ventricular filling pressures in patients with mitral valve stenosis : cardiovascular topic

SummaryBackgroundEstimation of left ventricular end-diastolic pressure (LVEDP) among patients with mitral valve disease may help to explain their symptoms. However, conventional Doppler measurements have limitations in predicting LVEDP in this group of patients. The aim of this study was to construct a Doppler-derived LVEDP prediction model based on the combined analysis of transmitral and pulmonary venous flow velocity curves.MethodsThirty-three patients with moderate to severe mitral stenosis (MS) who had indications for left heart catheterisation enrolled. Two-dimensional, M-mode, colour Doppler and tissue Doppler imaging indices, such as annular early diastolic velocity (Ea), isovolumic relaxation time (IVRT), pulmonary vein systolic and diastolic flow velocities, velocity propagation, left atrium area (LAA), interval between the onset of mitral E and annular Ea (TE–Ea), and Tei index were obtained. LVEDP was measured in all patients during left cardiac catheterisation. Linear correlation and multiple linear regressions were used for analysis.ResultsThe mean of LVEDP was 9.9 ± 5.3 mmHg. In univariate analysis, the only significant relationship was noted with LAA (p = 0.05, R2 = 0.11). However, in multivariate regression, LAA, Tei index and Ea remained in the model to predict LVEDP (p = 0.02, R2 = 0.26). For prediction of LVEDP ≥ 15 mmHg, the best model consisted of LAA, IVRT and Ea, and had a sensitivity of 85% and specificity of 85%.ConclusionOur results provided evidence that, in patients with moderate to severe MS, LVEDP can be estimated by combining Doppler echocardiographic variables of mitral flow. However, more studies are required to confirm these results.

English

BACKGROUND: Hypertension is the most common underlying cardiovascular disease in patients with isolated diastolic heart failure. Diastolic dysfunction in under detected in most hypertensive patients. MATERIAL AND METHODS: retrospective study carried out in Medicine department, SIMS, Shimoga for one year from June 2012 to June 2013. 50 patients who are hypertensive without any abnormality were studied general and systemic examination done, 2d echocardio graphy done in which transmitral flow velocity(E/A) is measured. RESULT: Most cases (60%) were between 31-50 yrs of age. Males constituted 58% and females 42% of the study group. 56% of cases had normal diastolic function as defined by E/A ratio(>1), as compared to 44% who had abnormal diastolic function. More than half of the cases with abnormal diastolic function (defined by abnormal E/A ratio<1) had duration of hypertension more than 12 months. Diastolic blood pressures <80 and ³90 mmHg were significantly associated with abnormal E/A ratio. CONCLUSION: Diastolic function assessment was done on asymptomatic ambulatory hypertensive patients. The abnormal diastolic function as assessed by abnormal E/A ratio was seen in 44% of cases. Both decreased and increased diastolic blood pressure was negatively and positively associated with diastolic dysfunction. The current study demonstrated that the presence of LV diastolic dysfunction in hypertensive patients is actually greater than previously reported by studies that analyzed transmitral flow velocity curves.

Diabetic Retinopathy is Associated With Impaired Left Ventricular Relaxation

Background Diabetic retinopathy (DR) is an independent predictor of heart failure (HF) in patients with diabetes mellitus (DM). However, it is unclear how DR is related to the development of HF. We hypothesized that DR is associated with left ventricular (LV) diastolic dysfunction, which is well recognized to subsequently result in HF. Methods and Results Data were collected in 63 consecutive patients with DM and LV ejection fraction (EF) ≥50%. Patients were excluded if they had HF diagnosed according to the modified Framingham criteria. Doppler echocardiographic indices including peak early-diastolic mitral annular movement velocity (E′) were obtained in each patient.We also assessed the diastolic index of echocardiographic color kinesis (CK-DI), which proportionally decreases with LV relaxation abnormality independently of LV filling pressure, as recently published. The DM patients were divided into groups without (DM-N; n = 30) and with (DM-DR; n = 33) DR. Age, gender, LV end-diastolic dimension, EF, E/A ratio of the transmitral flow velocity curves, E′, and E/E′ were not different between DM-N and DM-DR. However, CK-DI was significantly lower in DM-DR than DM-N. Conclusions DR is associated with LV diastolic dysfunction, and this may at least in part explain the increased incidence of HF in DM patients with DR.

Continuing Medical Education Activity in Echocardiography

Article Title: Transient Pseudorestic Pattern of Transmitral Flow Velocity Curve in Patients with Paroxysmal Atrial Fibrllation (Echocardiography 2011;28:288)

Transient Pseudorestrictive Pattern of Transmitral Flow Velocity Curve in Patients with Paroxysmal Atrial Fibrillation

Early diastolic velocity of the mitral annulus and transmitral flow propagation velocity are reported as more reliable determinants of left ventricular diastolic function in patients with atrial fibrillation than are transmitral Doppler indices. This study aimed to test the hypothesis that transmitral flow curve shows pseudorestrictive pattern during rate-controlled atrial fibrillation. Thirteen paroxysmal atrial fibrillation patients were monitored for three phases: before atrial fibrillation, during atrial fibrillation, and after the recovery of atrial fibrillation to sinus rhythm. Standard two-dimensional, color flow, and tissue Doppler echocardiography were performed. We compared the indices of left ventricular diastolic function among the three phases. The early diastolic velocity of transmitral flow increased significantly during atrial fibrillation (before, 0.76 ± 0.19 m/sec; during, 0.86 ± 0.20 m/sec; after recovery to sinus rhythm, 0.73 ± 0.16 m/sec; P < 0.01). The deceleration time of early transmitral diastolic wave decreased during atrial fibrillation (182.5 ± 39.6 ms; 149.1 ± 38.7 ms; 184.0 ± 44.5 ms, respectively, P < 0.01). The early diastolic velocity of the mitral annulus increased during atrial fibrillation (5.37 ± 1.31 cm/sec; 7.29 ± 1.25 cm/sec; 5.37 ± 1.32 cm/sec; respectively, P < 0.01). The transmitral propagation velocity did not change significantly during atrial fibrillation. Although conventional Doppler indices showed abnormal relaxation pattern, left ventricular diastolic function was preserved during rate-controlled atrial fibrillation, as determined from early diastolic velocity of the mitral annulus and transmitral flow propagation velocity.

Is newer better in the assessment of left ventricular diastolic function? Revival of left atrial size.

In assessing cardiac function, much attention has been paid to systolic function such as ejection fraction (EF), and the importance of diastolic function has been underestimated. However, 30–40% of patients with heart failure (HF) have preserved EF; their prognosis is as poor as HF patients with reduced EF, and diastolic dysfunction plays a crucial role in the pathogenesis of this type of HF. In addition, diastolic function is an independent determinant of prognosis even in HF patients with reduced EF. Based on these clinical findings, there is emerging interest in the assessment of diastolic function. In patients with reduced EF, increased ratio of early to late filling velocities of the transmitral flow velocity curves (E/A) and shortened deceleration time of E wave (DT) represent an elevation of left ventricular (LV) filling pressures secondary to LV diastolic dysfunction, indicating that evaluation of transmitral flow velocity curves is useful in assessment of severity of diastolic dysfunction. However, E/A ratio or DT does not correlate with LV filling pressure in subjects with preserved EF, and it is impossible to assess diastolic function and LV filling pressures in subjects with preserved EF using only transmitral flow velocity curves. Although combined analysis of transmitral and pulmonary venous flow velocity curves provides a reliable index for estimating LV filling pressure independent of EF, recording pulmonary venous flow velocity curves is not as easy as recording transmitral flow velocity curves. Tissue Doppler imaging has been utilized recently in clinical practice. Tissue Doppler imaging of mitral annular movement consists of systolic, early diastolic (e0), and late diastolic velocity curves, and several studies have demonstrated that the ratio of E to e0 (E/e0) correlated with LV filling pressure independent of EF. As tissue Doppler imaging of mitral annular movement is as easy as recording transmitral flow velocity curves, E/e0 ratio is currently used as a first line in diagnosing HF patients with preserved EF. However, several critical issues have been reported regarding the reliability of E/e0 ratio in assessing LV filling pressures. In patients with hypertrophic cardiomyopathy, E/e0 ratio may overestimate LV filling pressures. In patients with reduced EF and advanced decompensated HF, E/e0 ratio did not correlate with LV filling pressures, and E/A ratio was likely to show better correlation. In addition, ultrasound imaging machines without tissue Doppler imaging capability are still widely used by primary physicians, who are likely to follow more than half of HF patients with preserved EF in Japan. There has been growing interest in a newly developed technique, called speckle tracking, to assess cardiac function, and several articles have been published about the utility of this new method. However, analysis systems differ and the results are not consistent among ultrasound apparatuses. In assessing LV diastolic function, attention has been paid to the indices derived from LV echocardiographic imaging or flow dynamics during the diastolic phase. Left atrial (LA) size has been assessable by conventional echocardiography for a long time, but it has not been fully utilized in clinical practice. We previously showed that left atrium is enlarged in HF patients with preserved EF as K. Yamamoto (&) The Center for Advanced Medical Engineering and Informatics, Osaka University, 2-2 Yamadaoka, Suita 565-0871, Japan e-mail: kazuhiro@medone.med.osaka-u.ac.jp

Abstract 4203: Diastolic Wall Strain Can Noninvasively Predict Hemodynamic Deterioration Unassociated with Systolic Dysfunction in Hypertensive Hearts

This study examined whether LV diastolic wall strain (DWS) could noninvasively predict the transition to decompensated diastolic heart failure (DHF) in hypertensive hearts. Dahl salt-sensitive rats fed 0.3 % NaCl diet served as control group (group N: n=8) and those fed 8 % NaCl diet as hypertensive group (group HT: n=15). Serial Doppler echocardiographic studies were performed at age 13, 17 and 19 weeks. At 19 weeks, LV pressure was measured following the echocardiographic study. DWS was calculated as [(end-systolic thickness of LV posterior wall) - (end-diastolic thickness of LV posterior wall)]/(end-systolic thickness of LV posterior wall). Mid-wall fractional shortening (MFS) was not different between two groups at any stage. At 13 weeks (compensatory hypertrophic stage), the transmitral flow velocity curves (TMFV) represented the abnormal relaxation pattern with low E/A ratio in group HT. At 19 weeks (heart failure stage), E/A increased with the elevation of LV end-diastolic pressure and lung weight in group HT. DWS was not different between two groups at 13 weeks, however, its decrease preceded the pseudonormalization of TMFV at 17 weeks in group HT and continued until 19 weeks. The difference between the endocardial and epicardial movements is equal to that between the wall thickness at end-systole and end-diastole (a numerator of DWS). Therefore, based on the linear elastic theory, DWS is considered to decrease with increase of LV wall stiffness. We previously demonstrated that myocardial stiffness constant was elevated at age 17 weeks but not at age 13 weeks in Dahl salt-sensitive rats fed high-salt diet. The current results indicate that DWS is helpful in noninvasively predicting hemodynamic deterioration without the changes in systolic function, which is explained partly by the theory that DWS reflects LV wall stiffness. Echocardiographic Parameters and Hemodynamic Data in Control Group and Hypertensive Group

Noninvasive Assessment of Diastolic Function in Subjects With Preserved Left Ventricular Ejection Fraction: Usefulness of Color Kinetic Imaging

Background Noninvasive assessment of left ventricular (LV) diastolic function is not established in patients with preserved ejection fraction. We investigated a relation between diastolic function and diastolic wall dynamics. Methods and Results In the animal study, data were collected in hypertensive Dahl salt-sensitive rats, a diastolic heart failure (DHF) model (n = 35), and normotensive Dahl rats (n = 26). In the clinical study, echocardiography was conducted in 26 diabetic patients with normal ejection fraction and 10 age-matched controls. The diastolic index of color-encoded images (color kinesis diastolic index [CK-DI]) was calculated as the ratio of LV cavity area expansion during the first 30% of diastolic filling time to that during the whole diastolic filling period. In the DHF model, the E/A ratio of the transmitral flow velocity curves was pseudonormalized with the development of heart failure, but CK-DI was not. CK-DI, not E/A, was significantly and inversely correlated with the time constant of LV relaxation. Angiotensin receptor blocker improved LV relaxation in the DHF model and increased CK-DI, but not E/A. The diabetic patients showed lower CK-DI than the controls, although E/A was not different. Conclusion Color-encoded imaging is useful in evaluating LV diastolic function. The prevalence of LV diastolic dysfunction may have been clinically underestimated by the transmitral flow velocity curves.

Enzyme replacement therapy with agalsidase beta improves cardiac involvement in Fabry's disease.

Fabry's disease is an X-linked lysosomal storage disease caused by a deficiency of alpha-galactosidase that results in an accumulation of neutral glycosphingolipids throughout the body, including the cardiovascular system. Fabry cardiomyopathy, characterized by progressive severe concentric left ventricular (LV) hypertrophy, is very frequent and is the most important cause of death in affected patients. Enzyme replacement therapy (ERT) allows a specific treatment for this disease, however, there are very few data on the effectiveness of therapy on cardiac involvement. Nine patients with Fabry cardiac disease were studied on basal condition and after 6 and 12 months of treatment with algasidase beta (Fabrazyme). A complete clinical, electrocardiographic and echocardiographic evaluation was performed in all patients. Interpretable Doppler recordings of transmitral flow and pulmonary flow velocity curves were also acquired. At baseline, the patients with Fabry's disease had increased LV septum and posterior wall thickness, normal LV fractional shortening, LV ejection fraction, normal Doppler parameters of mitral inflow but a duration of pulmonary vein flow velocity wave exceeding that of the mitral wave at atrial systole. ERT did not affect heart rate and arterial pressure. LV internal diameters did not change, there was a slight but not significant decrease in the LV posterior wall thickening and a progressive decrease in the interventricular septum thickening (p < 0.025) and in LV mass (p < 0.001) The difference in duration between pulmonary vein flow velocity wave and mitral wave at atrial systole significantly decreased (p < 0.001). These results suggest that ERT in patients with Fabry cardiomyopathy is able to reduce the LV mass and ameliorate the LV stiffness.

Tachycardia during the valsalva maneuver: a sign of normal diastolic filling pressures

Alteration of the loading conditions during the Valsalva maneuver is a helpful ancillary method in the noninvasive assessment of diastolic filling of the heart by Doppler echocardiography. When tachycardia is induced by the maneuver, mitral inflow velocity curves may become uninterpretable because of E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and A velocity (the velocity at atrial contraction on the transmitral flow velocity curve) wave fusion. To determine the clinical significance of the E velocity and A velocity wave fusion, our study assessed the relation between the heart rate response induced by the Valsalva maneuver and the left ventricular filling pressures measured during cardiac catheterization. In all, 77 patients performed the maneuver during continuous hemodynamic and electrocardiographic monitoring. The ratio between the baseline R-R interval and the shortest R-R interval during the maneuver was calculated. A ratio value higher than 1.1 was predictive of a pre-A pressure of less than 18 mm Hg (94% positive predictive value). Reflex tachycardia during the Valsalva maneuver and subsequent fusion of the E velocity and A velocity waves on the mitral velocity curves is a sign of normal left ventricular filling pressures.

Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy

ObjectivesWe tested a hypothesis that elevation of the plasma level of brain natriuretic peptide (BNP) is one of the characteristics of patients with diastolic heart failure (DHF) independent of left ventricular (LV) hypertrophy. BackgroundThe clinical characteristics of DHF are not well acknowledged, although DHF has become a great social burden. Such a lack of clinical information leads to inaccuracy in the diagnosis of DHF. We have demonstrated enhancement of ventricular production of BNP with progression of maladaptive ventricular hypertrophy, but not with development of compensatory hypertrophy in an animal DHF model. MethodsOf 372 patients who presented to the emergency department because of acute pulmonary congestion without acute coronary syndrome between January 1996 and May 2002, those with an ejection fraction ≥45% upon admission, who were stably controlled at least for a year in our outpatient clinics, comprised the DHF group (n = 19). A control group consisted of 22 hypertensive patients with a LV mass index greater than or equal to its minimum value of the DHF group and an ejection fraction ≥45%, in whom cardiac symptoms had not occurred. ResultsDespite a similar distribution of LV mass index, the BNP level was higher in the DHF group than in the control group (149 ± 38 vs. 31 ± 5 pg/ml, p < 0.01). There was no difference in LV cavity size or parameters derived from pulsed Doppler transmitral flow velocity curves. ConclusionsAn elevation of BNP may be a hallmark of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.

In patients with severe systolic dysfunction, only brain natriuretic peptide is related to diastolic restrictive pattern

Background: In patients with severe systolic dysfunction the relationship between diastolic dysfunction and plasma levels of atrial and brain natriuretic peptide (ANP, BNP), catecholamines, renin, and aldosterone in patients with chronic heart failure (CHF) has never been investigated. Objectives: The aim of this study was to evaluate in clinically stable patients with severe systolic dysfunction whether the presence of diastolic restrictive pattern modifies neurohormonal plasma levels. Methods: Of 82 consecutive patients with stable CHF, 36 were in sinus rhythm, had an adequate ultrasound window and an ejection fraction <30%, and gave their written consent. Plasma levels of ANP, BNP, aldosterone, renin, epinephrine, and norepinephrine were assessed, and the diastolic function was evaluated by Doppler transmitral flow velocity curves. Results: Except for aldosterone, plasma levels of the other hormones were above normal range in most patients. Patients with restrictive pattern (22%) had BNP plasma levels significantly higher than patients with nonrestrictive pattern (78%): 251 ± 196 versus 44 ± 35 ng/L (P =.02). A BNP value of 72.6 ng/L had a sensitivity of 88%, with a specificity of 89% for detecting restrictive pattern in our population. Conclusion: In clinically stable patients with CHF and severe systolic dysfunction, BNP is the only neurohormone sensitive to the concomitant presence of a restrictive pattern.

Doppler-derived left ventricular end-diastolic pressure prediction model using the combined analysis of mitral and pulmonary A waves in patients with coronary artery disease and preserved left ventricular systolic function

The aim of this study was to analyze the components of mitral and pulmonary A waves and to construct a Doppler-derived left ventricular (LV) end-diastolic pressure (EDP) prediction model based on the combined analysis of transmitral and pulmonary venous flow velocity curves. Combined analysis of transmitral and pulmonary venous flow velocity curves at atrial contraction is a reliable predictor of increased LV filling pressure. The duration of pulmonary and mitral A waves is determined by the sum of respective acceleration and deceleration time. Mitral flow and left upper pulmonary vein flow velocity curves were recorded simultaneously with LVEDP in 40 consecutive patients (aged 59 ± 8 years) with coronary artery disease and preserved LV systolic function. Differences in all parameters represent values of pulmonary minus those of mitral A wave curve. The difference in deceleration time was the strongest candidate, being included in all models. After redundancy evaluation, we reached the following model: LVEDP = 20.61 + 0.229 × difference in deceleration time (r 2 = 0.80, p <0.001). In the entire study group, the difference in duration and in deceleration time of the A wave was highly correlated with LVEDP (r = 0.79, p <0.001, and r = 0.88, p <0.001, respectively). The entire study group was further divided according to whether LVEDP was above (group I, 20 patients) or below (group II, 20 patients) the median value (15.5 mm Hg). In group I, the difference in duration and in deceleration time correlated well (r = 0.62, p = 0.01, and r = 0.75, p = 0.001, respectively) with LVEDP, whereas in group II only the difference in deceleration time correlated well (r = 0.68, p = 0.005). In patients with coronary artery disease and preserved LV systolic function, the combined analysis of mitral and pulmonary A waves can predict LVEDP. The difference in deceleration time between pulmonary and mitral A waves can reliably evaluate high and normal LVEDP.

The importance of pulmonary venous flow measurement for evaluating left ventricular end-diastolic pressure in patients with coronary artery disease in the early stage of Diastolic Dysfunction

Transmitral flow pattern assessed by pulsed Doppler echocardiography is widely used to evaluate left ventricular end-diastolic pressure (LVEDP). A restrictive mitral flow pattern is well recognized as a finding of severely elevated LVEDP. On the other hand, an abnormal relaxation pattern can be interpreted many ways. For example, some patients who display an abnormal relaxation pattern have a mild impairment of left ventricular (LV) relaxation as a result of aging, and others have severely impaired LV diastolic function. To evaluate LVEDP in patients with abnormal relaxation mitral filling patterns, we studied 55 patients who had coronary artery disease with abnormal relaxation pattern who underwent elective cardiac catheterization. We recorded the transmitral and pulmonary venous flow velocity curves and measured the duration of the mitral A wave (MAd) and pulmonary venous reversal wave during atrial contraction (PAd). Positive correlations were found between PAd and LVEDP (r = 0.65, P <.01) and between PAd-MAd and LVEDP (r = 0.7, P <.0001); however, MAd was not significantly correlated with LVEDP. In conclusion, PAd must be measured for an accurate evaluation of LV end-diastolic pressure in patients with an abnormal relaxation pattern in the transmitral flow velocity curve.

Left Ventricular Diastolic Dysfunction in Patients With Hypertension and Preserved Systolic Function

To assess prospectively diastolic function in hypertensive patients with preserved left ventricular function, particularly focusing on the limitation of the transmitral flow velocity curve alone to detect diastolic dysfunction. Comprehensive Doppler analysis was performed in 51 hypertensive patients with preserved left ventricular systolic function. The ratio of the peak early diastolic filling wave velocity to the peak velocity of filling wave at atrial contraction was less than the age-adjusted mean value minus 2 SD in 16 patients, and the other 35 patients had a "normal" transmitral Doppler signal. However, the combined transmitral and pulmonary venous Doppler analysis revealed that 12 of these 35 patients had a "pseudonormal" pattern. The prevalence of diastolic dysfunction was estimated at 31% with use of transmitral Doppler alone but increased to 55% when comprehensive Doppler analysis was used (P < .05). The presence of diastolic dysfunction has been frequently overlooked in hypertensive patients with transmitral Doppler analysis alone, and an assessment of diastolic function with a comprehensive Doppler analysis is needed in patients at risk for diastolic dysfunction.

Doppler echocardiographic method to determine early and late diastolic filling volume separately. Validation and relationship between filling velocity and volume.

We devised a pulsed Doppler echocardiographic method of separately calculating early diastolic filling volume (EDFV) and late diastolic filling volume during atrial contraction (LDFV) and observed a relationship between diastolic filling volume and velocity in thirty patients with coronary artery disease. By analysing the transmitral flow velocity curve and mitral valve motion, EDFV and LDFV were measured on the basis of the equality of left ventricular inflow and outflow volumes. The Doppler-determined EDFV and LDFV correlated well with those obtained from the left ventricular filling curve produced by left ventriculography. Angiographic EDFV and LDFV were measured from the time (t)-volume (V) curve, using the t-dV/dt curve to define early and late diastolic phases. A good correlation was found between Doppler and angiographic EDFV (y = -3.0 + 1.0 x, r = 0.98, p = 0.0001, n = 20), Doppler and angiographic LDFV (y = 1.6 + 1.0 x, r = 0.86, p = 0.0001), and also between Doppler and angiographic EDFV/LDFV (y = 0.05 + 0.9 x, r = 0.93, p = 0.0001). EDFV and the peak early diastolic filling velocity were significantly correlated (E velocity; y = 25 + 0.51 x, r = 0.48, p = 0.0068), while LDFV and the peak late diastolic filling velocity during atrial contraction (A velocity) were not. Our results validate the method of calculating EDFV and LDFV separately and suggest that early diastole in the left ventricle has flow volume dependency, but that the late diastole filling velocity during atrial contraction may be regulated by other factors such as increased left atrial contraction.

Determination of Left Ventricular Filling Pressure by Doppler Echocardiography in Patients With Coronary Artery Disease: Critical Role of Left Ventricular Systolic Function

Objectives. This study was designed to determine the usefulness of transthoracic Doppler measurements in detecting increased left ventricular (LV) end-diastolic pressure in patients with coronary artery disease, specifically examining the influence of systolic function on the accuracy of these methods.Background. Studies that have correlated Doppler indexes with LV filling pressures primarily involved patients with LV systolic dysfunction. The reliability of Doppler indexes in estimating filling pressures in patients with coronary artery disease and preserved systolic function is unclear.Methods. Pulsed wave Doppler transmitral and pulmonary venous flow velocity curves and LV pressure were recorded in 83 patients with coronary artery disease.Results. Conventional Doppler indexes (deceleration time of mitral E wave velocity, ratio of peak mitral E to A wave velocities and pulmonary venous systolic fraction) correlated with LV filling pressure in patients with an ejection fraction (EF) ≤50% but not in those with an EF >50%. Previously published regression analysis for prediction of LV filling pressure was accurate in patients with an EF ≤50% but not in those with an EF >50%. The difference between flow duration with atrial contraction in the pulmonary veins and transmitral flow duration with atrial contraction correlated with LV filling pressure in both groups.Conclusions. Analysis of the early diastolic portion of the transmitral or pulmonary venous flow velocity curves can be used to predict LV filling pressures in patients with systolic dysfunction, but are inaccurate in patients with preserved systolic function. The combined analysis of both flow velocity curves at atrial contraction is a reliable, feasible predictor of increased LV filling pressure, irrespective of systolic function.

Evaluation of Diastolic Filling of Left Ventricle in Health and Disease: Doppler Echocardiography Is the Clinician’s Rosetta Stone

Abnormalities of diastolic function have a major role in producing the signs and symptoms of heart failure. However, diastolic function of the heart is a complex sequence of multiple interrelated events, and it has been difficult to understand, diagnose and treat the various abnormalities of diastolic filling that occur in patients with heart disease. Recently, Doppler echocardiography has been used to examine the different diastolic filling patterns of the left ventricle in health and disease, but confusion about diagnosis and treatment options has arisen because of the misinterpretation of these flow velocity curves. This review presents a simplified approach to understanding the process of diastolic filling of the left ventricle and interpreting the Doppler flow velocity curves as they relate to this process. It has been hypothesized that transmitral flow velocity curves show a progression over time with diseases involving the myocardium. This concept can be applied clinically to estimate left ventricular filling pressures and to predict prognosis in selected groups of patients. Specific therapy for diastolic dysfunction based on Doppler flow velocity curves is discussed.