Transmitral Inflow Pattern Research Articles

Additional heart sounds during early diastole in a patient with hypertrophic cardiomyopathy and atrioventricular block

A third heart sound (S3) and a fourth heart sound (S4) are similarly perceived as low-pitched sounds and can be difficult to distinguish in some conditions, such as tachycardia or arrhythmia. We report a case with hypertrophic cardiomyopathy and Wenckebach second-degree atrioventricular block, in which the S4 was initially misdiagnosed as an S3 on auscultation and later confirmed using a phonocardiogram with an apexcardiogram. Interestingly, the amplitude of the S4 dynamically and regularly fluctuated in proportion to the interval between the S4 and the preceding ventricular contraction. These findings were associated with transmitral inflow patterns assessed by Doppler echocardiography, highlighting the importance of not only transmitral A but also E waves for the amplitude of S4 in patients with arrhythmias.<Learning objective: A fourth heart sound could be difficult to diagnose and dynamically fluctuate in amplitude in patients with arrhythmias, such as Wenckebach second-degree atrioventricular block. These findings are likely to be associated with changes in transmitral inflow patterns assessed by Doppler echocardiography.>

Clinical impact of diastolic function after surgical ventricular restoration.

The impact of diastolic function on the clinical outcome of surgical ventricular restoration remains controversial. 71 patients undergoing surgical ventricular restoration between 1999 and 2012 were investigated. Perioperative echocardiographic parameters were compared, risk factors for deaths and cardiac events were analyzed, and actuarial freedom from death and cardiac events was computed. Preoperatively, the left ventricular end-systolic volume index was 77 ± 40 mL·m(-2) and left ventricular ejection fraction was 33% ± 11%. Postoperatively, left ventricular systolic function was significantly improved (end-systolic volume index 49 ± 31 mL·m(-2), ejection fraction 42.1% ± 11.7%) with a 33.8% ± 21.9% reduction in left ventricular end-systolic volume index. The transmitral filling deceleration time decreased from 198 ± 54 to 150 ± 46 ms, and the ratio of early peak filling velocities increased significantly postoperatively (from 16 ± 10 to 21 ± 17). Freedom from death and cardiac events at 5 years was 78% ± 5% and 64% ± 6%, respectively. Multivariate analyses revealed that age was a significant risk factor for all-cause death, postoperative transmitral inflow pattern for cardiac death, and preoperative mitral regurgitation and postoperative transmitral inflow pattern for cardiac events. Despite its positive impact on systolic function, surgical ventricular restoration negatively affects postoperative diastolic function. Postoperative severe diastolic dysfunction may correlate with late mortality and cardiac events.

Mechanism of exertional dyspnea in high output states: Is diastolic dysfunction a culprit? newer insights from doppler echocardiography

Background: The underlying mechanism of cardiac failure in high output states has not been clearly understood. It is well known that left ventricular systolic functional indices are usually preserved. So, what causes the symptoms of cardiac failure?. We analysed the LV diastolic parameters in some of the common high output states Aim: The aim of this study was to evaluate Left Ventricular (LV) diastolic function in various high output states. Study population: Comprising 185 patients, mean age -25 (20-30) years, of various high output states such as pregnancy 2nd trimester (24-28 wks), 3rd trimester (32-36 wks), Chronic kidney disease patients with patent arterio-venous fistula, Hyperthyroidism, Anemia with hemoglobin levels of 6-8 gm%, patients with normal left ventricular systolic function (EF 58-65%),functional class II or III were included in our study.Patients with co-morbid states fused trans-mitral inflow E/A velocities and arrhythmias were excluded. Methods: Echocardiographic evaluation of all patients was done using Philips HD7XE machine in our Echo lab. Diastolic function was assessed using conventional trans-mitral inflow pattern, Pulmonary venous flow, and mitral annular tissue Doppler imaging. Results: Results are shown in Table 1. View this table: Table 1 Conclusion: Diastolic LV function is relatively well preserved in most patients with physiologic high output states and it tends to get affected in pathologic high output states. It is likely that symptoms which suggest cardiac failure in some of these patients are not attributable to cardiac functional impairment as such. It is possible the symptoms of cardiac failure in high output states simply reflect hyper functioning heart due to increased metabolic demands.

Pro-Brain Natriuretic Peptide is a Sensitive Marker for Detecting Cardiac Metastases in Patients with Non-Small Cell Lung Cancer

Background: B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP) are important diagnostic tools for patients with suspected cardiac disorders. The aim of this study was to evaluate the predictive value of plasma NT-pro-BNP in identifying cardiac metastases in patients with non-small cell lung cancer (NSCLC) and dyspnoea. Patients and Methods: A total of 120 patients, median age 62 years (range 46–83), with NSCLC and dyspnoea were studied. Patients with heart failure or documented coronary artery disease were excluded. Echocardiographic imaging was used to detect cardiac metastases and estimate global left ventricular function. Ejection fraction and E/A ratio from transmitral inflow pattern were calculated. Plasma NT-pro-BNP was also measured. 72 patients (72/120, 60%) with cardiac metastases were identified. Results: NT-pro-BNP was significantly higher in patients with metastases (1347.5 ± 1004.30 pg/ml vs. 159.02 ± 93.29 pg/ml; p = 0.001). No differences between groups, regarding s-creatinine (p = 0.45), haemoglobin (p = 0.71), left ventricular hypertrophy (p = 0.91), and diastolic dysfunction (p = 0.79), were observed. Conclusion: Plasma NT-pro-BNP is remarkably elevated in patients with NSCLC and myocardial/pericardial infiltrations and may be used as a sensitive marker for detecting cardiac metastases in these patients.

Diastolic Dysfunction of the Cardiac Allograft and Maximal Exercise Capacity

Peak oxygen uptake (peak Vo(2)) is an established integrative measurement of maximal exercise capacity in cardiovascular disease. After heart transplantation (HTx) peak Vo(2) remains reduced despite normal systolic left ventricular function, which highlights the relevance of diastolic function. In this study we aim to characterize the predictive significance of cardiac allograft diastolic function for peak Vo(2). Peak Vo(2) was measured using a ramp protocol on a bicycle ergometer. Left ventricular (LV) diastolic function was assessed with tissue Doppler imaging sizing the velocity of the early (Ea) and late (Aa) apical movement of the mitral annulus, and conventional Doppler measuring early (E) and late (A) diastolic transmitral flow propagation. Correlation coefficients were calculated and linear regression models fitted. The post-transplant time interval of the 39 HTxs ranged from 0.4 to 20.1 years. The mean age of the recipients was 55 +/- 14 years and body mass index (BMI) was 25.4 +/- 3.9 kg/m(2). Mean LV ejection fraction was 62 +/- 4%, mean LV mass index 108 +/- 22 g/m(2) and mean peak Vo(2) 20.1 +/- 6.3 ml/kg/min. Peak Vo(2) was reduced in patients with more severe diastolic dysfunction (pseudonormal or restrictive transmitral inflow pattern), or when E/Ea was > or =10. Peak Vo(2) correlated with recipient age (r = -0.643, p < 0.001), peak heart rate (r = 0.616, p < 0.001) and BMI (r = -0.417, p = 0.008). Of all echocardiographic measurements, Ea (r = 0.561, p < 0.001) and Ea/Aa (r = 0.495, p = 0.002) correlated best. Multivariate analysis identified age, heart rate, BMI and Ea/Aa as independent predictors of peak Vo(2). Diastolic dysfunction is relevant for the limitation of maximal exercise capacity after HTx.

Intra-operative myocardial ischaemia cannot be detected by analysis of transmitral inflow patterns in patients undergoing off-pump coronary surgery

Transmitral inflow patterns have been used for detection of myocardial ischaemia. However, its diagnostic value has not been tested in anaesthetized and mechanically ventilated patients undergoing coronary artery bypass graft surgery. Transmitral inflow patterns were studied by transoesophageal Doppler echocardiography in 43 patients undergoing coronary artery bypass graft surgery without cardiopulmonary bypass after opening of the sternum (baseline) and during grafting of the left anterior descending artery. Peak early (E) and peak late (A) transmitral velocities and their ratio (E/A) were recorded. Myocardial ischaemia was defined by standard criteria using two-dimensional echocardiography and seven-lead electrocardiogram. Thirty-one patients (64 +/- 8 yr, 9 women) fulfilled the predefined inclusion criteria for analysis. During distal revascularization, 16 patients showed myocardial ischaemia and 15 did not. The use of vasoactive drugs, haemodynamic findings and transmitral inflow patterns were similar in both groups at baseline and during grafting. In the ischaemic group, E was 67.1 +/- 13.9 cm s-1 at baseline and 69.5 +/- 23.2 cm s-1 during grafting, and the E/A ratios were 1.3 +/- 0.3 and 1.4 +/- 0.9, respectively. In the non-ischaemic group, E was 64.0 +/- 17.1 cm s-1 at baseline and 60.9 +/- 14.8 cm s-1 during grafting, and the E/A ratios were 1.4 +/- 0.7 and 1.2 +/- 0.3, respectively. Analysis of Doppler findings of transmitral inflow patterns did not allow for detection of myocardial ischaemia during surgical revascularization of the myocardium.

Positive end-expiratory pressure does not influence Doppler-derived ventriculoatrial pressure gradient and Tei index in critically ill p

Echocardiographic parameters of left ventricular (LV) systolic and diastolic function usually include LV dimensions, ejection fraction and transmitral inflow patterns. In mechanically ventilated patients, the use of positive end-expiratory pressure (PEEP) reduces LV preload and afterload and thus may confound accurate assessment of these markers, as they are known to be load dependent. The myocardial performance index (Tei index) and the Doppler-derived ventriculoatrial pressure gradients dP/dt and –dP/dt are known to be less load-dependent and may therefore be more accurate markers to characterize LV-function under PEEP conditions. We consecutively studied ten mechanically ventilated, critically ill patients with mild mitral regurgitation. Each patient was examined at two PEEP levels, 5 and 15 mbar. At each PEEP level, transthoracic echocardiography was performed to assess the parameters of LV function. Moreover, blood pressure measurements and respiratory parameters were recorded. Blood pressure and minute ventilation did not change at either PEEP level. Left ventricular dimensions and ejection fraction decreased significantly at increased PEEP, whereas Tei index and dP/dt remained unchanged. Only moderate correlations between ejection fraction and Tei index or dP/dt could be observed. Increased PEEP did not influence transmitral inflow patterns and –dP/dt. Tei index and Doppler-derived dP/dt serve as accurate markers of LV performance independent of loading conditions in mechanically ventilated patients, as they are not influenced by PEEP.

Endothelial function and arterial stiffness in sickle-thalassemia patients

Background Homozygous sickle-cell anemia and β-thalassemia are characterized by impaired endothelial function, while data on arterial stiffness have hitherto been conflicting. We sought to investigate aortic elastic properties and endothelial function in sickle-thalassemia, which combines molecular and clinical features of the above conditions. Methods and results Forty-seven sickle-thalassemia patients, younger than 45 years, with preserved left ventricular (LV) function and no history of smoking, systemic or pulmonary hypertension, diabetes mellitus, dyslipidemia or thyroid disease, along with 40 healthy controls were studied. Aortic strain, distensibility and stiffness index were calculated by echocardiographically-obtained aortic root diameters. Brachial artery endothelial function was assessed by ultrasonographic evaluation of flow-mediated dilatation (FMD) and nitrate-mediated dilatation (NMD). Left ventricle was assessed by echocardiography. Patients had an impaired FMD (4.2 ± 2.9% versus 9.2 ± 3.8% in controls, p < 0.001) with a preserved NMD (16.9 ± 5.6% versus 15.2 ± 4.8% in controls, p > 0.05). Aortic strain and distensibility were lower and aortic stiffness index was higher in patients compared to controls (8.1 ± 4.6 versus 5.8 ± 2.9, p < 0.01). Indexed LV diameters and mass were higher in patients. Systolic LV function was preserved, while 14.9% of patients had an impaired relaxation transmitral inflow pattern. Patients’ LV mass index and diastolic mitral E wave deceleration time were positively correlated with aortic stiffness index ( p < 0.001). Conclusion Sickle-thalassemia is characterized by a complex vasculopathy, consisting of endothelial dysfunction and increased arterial stiffness, with a global effect on cardiovascular function.

Characteristics of Left Ventricular Diastolic Function in Patients with Systolic Heart Failure: A Doppler Tissue Imaging Study

Our aim was to characterize myocardial velocity profiles in different types of diastolic dysfunction for patients with severely decreased left ventricular (LV) systolic function. A total of 126 patients with congestive heart failure and an LV ejection fraction of 35% or less were included. Patients underwent an echocardiographic Doppler examination, with measurement of the transmitral inflow pattern, and Doppler tissue imaging of the mitral annulus. Compared with age-matched control subjects, the patients had decreased systolic (9.5 vs 4.9 cm/s, P < .001) and early diastolic (11.6 vs 5.6 cm/s, P < .001) mitral annular velocities. According to the transmitral inflow pattern, 56 patients had signs of a LV restrictive pattern, 36 had a pseudonormalization pattern, and 34 had an abnormal relaxation pattern. The peak systolic and early diastolic mitral annular velocities were quite similarly reduced in different diastolic groups (systolic velocities of 4.6, 5.0, and 5.3 cm/s, and early diastolic velocities of 5.7, 5.8, and 5.1 cm/s at restrictive, pseudonormal, and abnormal relaxation, respectively). The ratio of the transmitral early wave and mitral annular early velocity, an expression of LV filling pressure, was highest in the restrictive group compared with other groups (17.0, 14.6, and 11.7 in the above 3 groups, respectively, P < .001 among groups). The ratio of the transmitral early wave and mitral annular early velocity was also higher in the pseudonormal group than in a control group of patients with ejection fraction of 35% or more with signs of a normal/pseudonormal pattern (14.6 vs 9.0, P < .001). Doppler tissue imaging may enhance the estimates of diastolic dysfunction in patients with decreased LV systolic function, and help to disclose abnormal diastolic function especially in a pseudonormal group.

Regression of left ventricular hypertrophy and improvement of diastolic function in hypertensive patients treated with telmisartan

Objectives: The study was designed to test whether or not the angiotensin II receptor blocker telmisartan brings about regression of left ventricular (LV) concentric hypertrophy and whether or not these changes are associated with improved diastolic filling. Methods: An echocardiographic follow-up study was performed in 85 hypertensive patients (systolic blood pressure [SBP] >140 mm Hg, diastolic blood pressure [DBP] >90 mm Hg) and mild-to-moderate LV hypertrophy (LV mass index related to body surface area [LVMI] 117–150 g/m 2 for men and 105–150 g/m 2 for women) treated with telmisartan monotherapy 40–80 mg once daily for 1 year. Blood pressure, LVMI, left atrial (LA) volumes, and diastolic function were determined at baseline and after 3, 6, 9, and 12 months of treatment. Blood pressure was also monitored at all visits. Diastolic function was assessed by examination of transmitral inflow and pulmonary vein flow patterns. Results: Telmisartan reduced blood pressure; after 12 months, the mean±S.D. SBP and DBP were reduced from 144±10 to 126±8 mm Hg ( p<0.001) and from 98±8 to 86±7 mm Hg ( p<0.001), respectively. The LVMI was decreased from 119±7 to 109±3 g/m 2 ( p<0.001) after 12 months' telmisartan treatment. All patients had diastolic dysfunction at baseline. After 12 months' telmisartan treatment, a normal pattern of transmitral inflow was present in 21% of patients. The regression of LV hypertrophy observed after 12 months was associated with increased peak early diastolic velocity/peak late diastolic velocity ratio from 0.60±0.18 to 0.83±0.20 ( p<0.001), shortened isovolumic relaxation time (IVRT) from 110±13 to 105±13 ms ( p<0.001), and decreased deceleration time from 229±30 to 215±28 ms ( p=0.002). Univariate analysis showed that shortened IVRT was related to a reduction in the LVMI and LA maximal and minimal volumes. In the multivariate analysis, the reduction in LVMI and the reduction in LA maximal and minimal volumes were independently associated with IVRT reduction. Conclusions: Telmisartan 40–80 mg is effective in LV hypertrophy regression in hypertensive patients. The reduction in LVMI due to telmisartan monotherapy was associated with a significant improvement of diastolic filling parameters and with a significant reduction of LA volumes.

Is the Ratio of Transmitral Peak E-Wave Velocity to Color Flow Propagation Velocity Useful for Evaluating the Severity of Heart Failure in Atrial Fibrillation?

Although analysis of the transmitral inflow (TMF) pattern is widely used for evaluating left ventricular diastolic function and provides valuable information for the management of heart failure (HF) in sinus rhythm, its utility in patients with atrial fibrillation (AF) has not been established. The aim of this study was to investigate the relationship between the ratio of transmitral peak E-wave velocity to flow propagation velocity (E/Vp) obtained by a newly developed dual Doppler system and the plasma B-type natriuretic peptide (BNP) concentration or pulmonary capillary wedge pressure (PCWP) for evaluating the severity of heart failure with AF. In 68 patients with AF, the E/Vp was compared with plasma BNP concentration and PCWP. A cutoff value of > or =1.7 for E/Vp predicted a plasma BNP concentrationl of > or =200 pg/ml, with 80% sensitivity and 84% specificity. Only E/Vp was found to be independently significant by stepwise multilinear regression analysis (r=0.40, p=0.01). PCWP values had good correlation with E/Vp (r=0.63, p<0.01) and were significantly higher in the group with E/Vp >/=1.7 (16+/-6 mmHg vs 11+/-4 mmHg, p<0.05). The Doppler-derived index of E/Vp correlated well with the neurohormonal and hemodynamic parameters, and was useful for evaluating the severity of heart failure with AF.

Effects of treadmill exercise on mitral inflow and annular velocities in healthy adults

Tissue Doppler echocardiography has recently been introduced as a method to evaluate diastolic function by measuring diastolic mitral annular velocity. 1,2 Mitral annular velocity derived by tissue Doppler echocardiography is relatively independent of preload, and tissue Doppler echocardiography combined with transmitral flow velocity appears to provide a better estimate of left ventricular (LV) filling pressures compared with other methods, such as pulmonary venous flow pattern or preload reduction. 3 However, exerciseinduced changes in tissue Doppler echocardiography and mitral inflow velocities have not been characterized adequately. The purpose of this study was to evaluate transmitral inflow pattern and the tissue Doppler echocardiographic profile of a mitral annulus in healthy subjects during exercise; this would establish normal reference values to be used in a stress test to assess the extent of the elevation in diastolic filling pressure with exercise. ••• The study group was composed of 31 healthy subjects (13 men and 18 women, aged 59 14 years) without a history of hypertension, ischemic heart disease, cardiovascular symptoms, regular cardiac medication, or abnormal stress test results. Baseline measures of clinical characteristics, hemodynamic variables, mitral inflow, and diastolic velocities of the mitral annulus were obtained in all patients before exercise testing. This study was approved by the Mayo Foundation institutional review board. All subjects underwent a symptom-limited treadmill exercise test using the Bruce protocol. Blood pressure was obtained by a cuff sphygmomanometer at the 3-minute mark of each stage and at peak exercise. The 12-lead electrocardiogram was continuously monitored. All 2-dimensional and Doppler echocardiograms were recorded using a commercially available echocardiographic unit equipped with an imaging transducer and pulse-wave Doppler capability. Ejection fraction was calculated on the basis of 2-dimensional echocardiography and a modification of the method of

Transmitral Inflow Pattern Assessed by Doppler Echocardiography in Angiotensin II Type 1A Receptor Knockout Mice With Myocardial Infarction

Many studies have suggested that the renin-angiotensin system plays an important role in the left ventricular (LV) remodeling and cardiac dysfunction that occurs after myocardial infarction (MI). Although angiotensin II type IA (AT1A) receptor knockout (KO) mice are reported to display less LV remodeling after MI, diastolic dysfunction has not been fully evaluated, so the present study measured transmitral inflow pattern in both AT1A receptor KO mice with MI (KO-MI) and wild type mice with MI (WT-MI). Cardiac geometry and function were examined by Doppler echocardiography and myocardial mRNA expression was determined by Northern blot analysis at 4 weeks after MI. The LV internal diastolic dimension of WT-MI was larger than that of the KO-MI (p<0.05). Marked increases in the E wave velocity and the ratio of the peak velocity of the E wave to the A wave were observed in the WT-MI (p<0.01). The deceleration rate of the E wave in KO-MI was lower than in WT-MI (p<0.05). mRNA expressions of ANP, BNP, collagen I and collagen III in the non-infarcted LV and RV of KO-MI were significantly lower than WT-MI. In conclusion, transmitral inflow abnormalities in KO-MI were attenuated compared with WT-MI.

Left Ventricular End-Diastolic Pressure Can Be Estimated by Either Changes in Transmitral Inflow Pattern During Valsalva Maneuver or Analysis of Pulmonary Venous Flow

We directly compared the transmitral inflow pattern during preload reduction and pulmonary venous flow velocities to determine left ventricular end-diastolic pressure (LVEDP) in 78 patients who underwent left heart catheterization. Transmitral inflow indexes (A-wave duration, ratio of peak flow velocity of early diastole [E] to peak flow velocity of late diastole during atrial contraction [A] [E/A ratio]) at rest and during the Valsalva maneuver (30 mm Hg for 15 seconds) and indexes of pulmonary venous flow (velocity and duration of the atrial reversal) were obtained. Fair correlations existed between LVEDP (mean 15 ± 6 mm Hg) and the percentage decrease in the E/A ratio (r = 0.72), increase in duration of A wave during the Valsalva maneuver (r = 0.60), flow velocity of atrial reversal (r = 0.58), and difference of duration of atrial flow reversal and A wave (r = 0.62) (all P <.001). While sensitivity, specificity, and diagnostic accuracy to detect an elevated LVEDP were comparable, technically adequate Doppler recordings were obtained more often for the mitral inflow during the Valsalva maneuver than for the pulmonary venous flow (72 versus 66 patients, P < 0.05). (J Am Soc Echocardiogr 2000;13:599-607.)

Comparison of left ventricular diastolic filling with myocyte bulk modulus using Doppler echocardiography and acoustic microscopy in pressure-overload left ventricular hypertrophy and cardiac amyloidosis.

The myocardial bulk modulus has been described as the constitutive properties of the left ventricular (LV) wall and is measured as rho V2 (rho = density, V = sound speed) using acoustic microscopy. The study was undertaken to assess the relationship between the myocyte bulk modulus and transmitral inflow patterns in patients with pressure-overload LV hypertrophy (LVH) and cardiac amyloidosis (AMD). In 8 patients with LVH, 8 with AMD, and 10 controls without heart disease, the transmitral inflow pattern was recorded by Doppler echocardiography before death, and myocardial tissue specimens were obtained at autopsy. The tissue density and sound speed in the myocytes were measured by microgravimetry and acoustic microscopy, respectively. The diameters of the myocytes were measured on histopathologic specimens stained by the elastica Van Gieson method. In the subendocardium, the myocyte bulk modulus was larger in LVH (2.98 x 10(9) N/m2, p < 0.001) and smaller in AMD (2.61 x 10(9) N/m2, p < 0.001) than in the controls (2.87 x 10(9) N/m2). The myocyte diameter in LVH (26 +/- 1 microns) was larger than that in the control (21 +/- 1 microns, p < 0.001) and AMD (20 +/- 1 microns, p < 0.001). The bulk modulus in the subendocardial myocyte significantly correlated with the deceleration time (DT) of the early transmitral inflow (r = 0.689, p = 0.028 in control, r = 0.774, p = 0.024 in LVH, and r = 0.786, p = 0.021 in AMD). The changes in the myocyte elasticity as represented by the bulk modulus were limited to the subendocardial layers and may be related to relaxation abnormalities in LVH and a reduction in LV compliance in AMD.

Doppler echocardiographic parameters predictive of recurrence of atrial fibrillation of different etiologic origins.

Atrial fibrillation is a common arrhythmia associated with an increased risk for the occurrence of embolism. Recurrences of atrial fibrillation are very frequent and increase the risk for an embolic event. The aim of the present study was to identify the clinical and echocardiographic parameters that are predictive of the recurrence of atrial fibrillation. One hundred and twenty consecutive patients with non-rheumatic atrial fibrillation were followed for 1 year after cardioversion. The following parameters were evaluated: cause and duration of atrial fibrillation, modality of cardioversion, atrial function after cardioversion (peak A wave velocity and A wave integral), left atrial dimension, peak E wave velocity of the transmitral inflow pattern, acceleration and deceleration times, and the integral of E wave. At 1 year, 72 patients maintained sinus rhythm whereas 48 patients had a recurrence of atrial fibrillation. The univariate analysis revealed that the parameter with the strongest influence on the recurrence of atrial fibrillation was the peak A velocity after cardioversion (P < 0.001). The other parameters associated with recurrences were cause of atrial fibrillation (P < 0.001), duration of arrhythmia (P = 0.002), and left atrial dimension (P = 0.05). The modality of cardioversion and the E wave variables did not influence the recurrence of atrial fibrillation. The peak A velocity was smaller in the group of patients who had a recurrence. We suggest that clinical and echocardiographic parameters, such as A wave variables, be used to identify patients at risk for recurrence. These patients should be monitored more frequently and should eventually be treated with antiarrhythmic drugs.

Restoration of atrial function after atrial fibrillation of different etiological origins.

In order to evaluate atrial function after the restoration of normal sinus rhythm in patients with atrial fibrillation, an echocardiographic study was performed in 60 patients hospitalized for atrial fibrillation that was subsequently converted to sinus rhythm. The study population consisted of 60 patients, 41 males and 19 females, with a mean age of 67 +/- 8 years. In etiological terms, 20 patients had atrial fibrillation with no associated pathology, 20 had an underlying ischemic cardiopathy and 20 had hypertension. The duration of atrial fibrillation varied from 24 h to 6 months. The restoration of sinus rhythm was spontaneous in 20 patients and drug induced in 40. Patients were divided into groups on the basis of the duration of the atrial fibrillation, the etiology of the atrial fibrillation and the size of the atrium. Transmitral Doppler inflow patterns at rest were assessed within 24 h after conversion to sinus rhythm, and 1 week, 1 month and 3 months later. The statistical significance of serial changes in peak A velocity and A wave integral was determined by analysis of variance. Using the peak A wave for atrial filling and the velocity-time integral as the index of atrial mechanical function, the following results were obtained: restoration of atrial mechanical function occurred earlier in hypertensive patients and in patients with atrial fibrillation only than in patients with associated ischemic cardiopathy. Restoration also occurred earlier in the group of patients that had atrial fibrillation for < 24 h and in patients whose left atrium was of normal size. Since the mechanical activity of the left atrium, evaluated as the peak A wave, does not necessarily return immediately after the restoration of sinus rhythm, a follow-up assessment of the contraction of the left atrium is appropriate.

Determinants of transmitral inflow pattern 10–14 days after acute myocardial infarction

The administration of thrombolytic therapy after an acute myocardial infarction can reduce the size of the infarct and improve left ventricular function. We used pulsed Doppler to assess left ventricular diastolic function after an acute myocardial infarction in patients treated with recombinant tissue plasminogen activator (rTPA). We studied 104 patients after an acute myocardial infarction, 48 treated with a placebo and 56 with rTPA. They were compared with 36 age-matched controls. The Doppler parameters measured included the early peak in diastolic flow velocity, the peak during atrial contraction, the atrial: early ratio, mean deceleration, deceleration time, and half-filling fraction. Doppler parameters for large and small infarct sizes were compared. The Doppler parameters did not differ between treatment groups. Compared with the normal controls, significant differences were observed in both treatment groups for the early peak (placebo P < 0.05; rTPA P < 0.001), the atrial: early ratio (placebo P < 0.05; rTPA P < 0.01), and the half-filling fraction (P < 0.001 for both). In patients with large infarcts, the atrial peak was depressed (P = 0.008). Multivariate analysis showed that end-diastolic pressure, age, end-systolic volume, and regional wall motion parameters were major predictors of Doppler parameters.

The factor dominating the determination of left ventricular filling varies during the first five days after acute myocardial infarction

Left ventricular diastolic dysfunction may occur after the onset of acute myocardial infarction. Left ventricular diastolic filling dynamics are related to many factors. To evaluate the influence of left ventricular filling pressure on Doppler-derived left ventricular diastolic flow profiles in patients with acute myocardial infarction, we studied serial changes in filling during the first 5 days after the onset of uncomplicated acute myocardial infarction. The study population consisted of 14 patients with acute myocardial infarction and 15 normal subjects: Doppler echocardiographic studies (left ventricular transmitral inflow and outflow velocity patterns) were performed on admission, and on the third and fifth days after infarction. Hemodynamic parameters were measured simultaneously using Doppler echocardiography. The E wave was lower, the A wave and A:E ratio were higher, deceleration half time and isometric relaxation time were prolonged, and peak left ventricular ejection flow velocity was lower in myocardial infarction patients than in normal subjects. The E wave and pulmonary capillary wedge pressure were positively correlated on the first and the third day (r = 0.77, P < 0.001, and r = 0.67, P < 0.01, respectively), but not on the fifth day. The E wave and isometric relaxation time were negatively correlated on the fifth day (r = -0.72, P < 0.01), but not on the first and third day. Left ventricular filling pressure (preload) was an important mechanism for maintaining left ventricular filling during the first 3 days, but the relaxation of the ventricle began to play a dominant role on the fifth day.

Atrial ejection force: A noninvasive assessment of atrial systolic function

Objectives. The purpose of this study was to define atrial ejection force and to develop a method for its noninvasive measurement from echocardiographic data.Background. Assessment of diastolic function through measurement of the components of ventricular filling has largely neglected the vigor of atrial systole, in part because this has been difficult to quantify. However, atrial ejection force, defined as that force exerted by the left atrium to accelerate blood into the left ventricle during atrial systole, can be assessed noninvasively by combined two-dimensional imaging and Doppler echocardiography. This index of atrial function, based on classic newtonian mechanics, provides a physiologic assessment of atrial systolic function.Methods. To evaluate the usefulness of atrial ejection force, we studied the return of left atrial ejection force in 29 patients after elective cardioversion for atrial fibrillation. Transmitral Doppler inflow patterns at rest were assessed immediately after cardioversion and at 24 h, 1 week, 1 month and >3 months later. A healthy adult group (n = 10) served as control subjects.Results. After successful cardioversion, atrial ejection force was significantly depressed compared with that in the control group (5.2 ± 6.8 vs. 16.3 ± 4,7 kdynes; p < 0.0001). Over successive weeks, atrial ejection force improved in the subgroup of patients who remained in sinus rhythm (n = 18), whereas no improvement was seen during the period of maintained sinus rhythm in the patients with subsequent reversion to atriai fibrillation (n = 11).Conclusions. Atrial ejection force provides a physiologic assessment of atrial systolic function and is a potentially useful index for assessing atrial contribution to diastolic performance. In patients who successfully underwent cardioversion from atrial fibrillation, atrial ejection force improved over several weeks only in the subgroup in which sinus rhythm was maintained.