Clinical validity of a novel doppler time interval, in assessment of left ventricular filling pressure in patients with severe mitral stenosis

Non invasive assessment of diastolic filling pressure by Doppler echocardiography is important for the interpretation of symptoms and optimization of unloading therapy in patients with severe mitral stenosis. Recently a novel Doppler time interval between the onset of early diastolic velocity mitral inflow velocity [E] and annular early diatolic velocity [Ea] by tissue Doppler imaging [T[E-Ea]], have been proposed as one of the useful indices for this assessment. Therefore, this research was intended to assess the clinical utility of this time interval [T[E-Ea], have been proposed as one of the useful indices for this assessment. Therefore, this research was intended to assess the clinical utility of this time interval [T[E-Ea] for evaluation and prediction of pulmonary capillary wedge pressure [PCWP] in patients with severe mitral stenosis. Fifty patients with severe mitral stenosis were subjected to conventional and Tissue Doppler Imaging echocardiography to estimate the time interval [T[E-Ea], and all the routine 2D, M-mode, and Doppler echocardiographic measurement were taken, simultaneously right side heart catheterization for assessment of pulmonary capillary wedge pressure was done [as can as possible] before and after balloon mitral valvuloplasty. The mean age was [26.7 +/- 5.1 years], mitral valve area range was [0.8 to 1.2Cm[2]], and before mitral valvuloplasty the estimated PCWP [by Doppler equations] was [30.8 +/- 15.3] and assessed one [by catheterization] was [30.2 +/- 14.1 for], where both values were nearly comparable. While among several Doppler measurements the strongest correlation with PCWP had been observed with Isovolumetric Relaxation Time/time constant of LV relaxation [IVRT/Tau] where [r=-0.96, p<0.001] followed by IVRT/TE-Ea [r=-0.40, p<0.001]. Also, the same previous Doppler ratios tracked well the changes in PCWP after mitral valve dilatation, and both of them were able to predict PCWP. While other Doppler parameters failed to predict it. Importantly the cutoff value to predict PCWP> 15mmHg in mitral stenosis patients, was an IVRT/T[E-Ea] <4.7 with sensitivity and specificity of 100%. Time interval [T[E-Ea] is a useful novel Doppler index for evaluation of filling pressure, since the ratios of IVRT/T[E-Ea] or IVRT to Tau were more accurate than IVRT alone when correlated to PCWP or predict it in patients with severe mitral stenosis, as well it can track changes in PCWP after mitral valvuloplasty. Clinical Implication: Such simple equation could be used for daily application and one can use the simple ratio of IVRT/T[E-Ea] to predict PCWP> 15mmHg in patients with severe mitral stenosis and that well help to decide therapeutic strategies for such patients

applicable conventional echocardiographic evaluation of right ventricular function in chronic obstructive pulmonary disease

Several recent studies confirmed that echocardiography is valuable for accurate evaluation of right ventricular function in chronic obstructive pulmonary disease [COPD]. Our aim in this study was the assessment of the suitability and objectivity of two simple conventional echocardiographic techniques named; tricuspid valve annulus excursion and right ventricular outflow tract fractional shorting%, for estimating right ventricular function in patients chronic obstructive pulmonary disease. Also analyze their relation to tissue Doppler imaging which considered as an established parameter for assessing right ventricular function in such patients. A total of 30 patients with history of chronic obstructive pulmonary disease [group A] and 20 normal volunteers as a control group [group B] were studied by transthoracic echocardiography. Firstly conventional 2D and M-mode Echo done to estimate cardiac chambers internal dimensions with right ventricular outflow tract fractional shorting [FS%] and tricuspid valve annulus excursion. After that conventional Doppler applied for recording the Doppler flow of tricuspid and pulmonary valves. Finally; we assessed tricuspid valve annulus velocities by tissue Doppler imaging. The mean right ventricular out flow tract FS% in patients group was 17.5 +/- 2.8 and 28.9 +/- 5.4 in control group, while the mean Tricuspid valve annulus excursion was [21.5+6.77 and 31.4+8.74] in both of them respectively with a highly statistically significant difference. Tissue Doppler imaging tricuspid valve annulus S[m] and E[m] waves, E[m]/A[m] ratio as well as E[m] wave deceleration time were significantly differ in-between the two groups [p<0.05]. On the other hand there was statistically positive correlation between the M-mode right ventricular outflow tract FS% and the tricuspid valve annulus S[m], E[m] and E[m]/A[m] ratio by tissue Doppler imaging [p<0.001], while p was <0.00001 between the same tissue Doppler variables and the M-mode tricuspid valve annulus excursion. We concluded that tricuspid valve annular motion velocities derived by tissue Doppler imaging in chronic obstructive pulmonary disease patients is an accurate tool for assessing right ventricular function, but M-mode tricuspid valve annulus excursion alternatively is an easy applicable predictor for right ventricular function with good diagnostic power nearer to that derived by tissue Doppler imaging. In chronic obstructive pulmonary disease, the right ventricular function should be assessed by a simple easy applicable method during routine conventional echocardiography and so, we recommend M-mode tricuspid valve annulus excursion for this assessment, [and to a lesser extend the right ventricular outflow tract fractional shorting%]

QRS duration in isolated left bundle branch block: a marker of ventricular remodling and septal hypoperfusion

Isolated left bundle branch block [LBBB] per se may compromise cardiac mechanics and perfusion; this may contribute to the unfavorable outcome of such patients. The relation of QRS duration in isolated LBBB with cardiac function and perfusion is unknown. So, we sought to evaluate the left ventricular [LV] function and myocardial perfusion in isolated LBBB in relation to QRS duration. The study included 30 patients with isolated LBBB and 10 age and gender matched subjects without conduction delay. All study population had normal coronary angiogram. LBBB patients were divided into group I [17 patients] with 120/=140 msec. LV end diastolic dimension [LVED], LV end systolic dimension [LVES], septal wall thickness [SWT], posterior wall thickness [PWT] and LV ejection fraction [LVEF] were detected by echocardiography and myocardial perfusion was assessed by Thallium-201 [[201]Th] scintigraphy. LV remodeling [as detected from increased LVSD and PWT and decreased LVEF] and septal hypoperfusion [as detected by 201Th scintigraphy] were more frequent in group II [patients with QRS>140 msec]. QRS as it correlated positively with LVES [r 0.79, p<0.001] and negatively with LVEF [r-0.56, p<0.002], it also showed good agreement with myocardial perfusion imaging, the prolonged QRS the more frequent septal hypoperfusion. Moreover, there was a relation between cardiac function and myocardial perfusion in LBBB patients as these patients with perfusion defects showed increased LVES and SWT and decreased LVEF versus those without perfusion defects suggesting that there is link between cardiac function and myocardial perfusion in LBBB. Electrocardiography is commonly used as the first assessment tool for possible cardiac disease. QRS duration in patients with isolated LBBB is closely related to LV remodeling and septal hypoperfusion

Right ventricular dysfunction type in idiopathic and Ischemic cardiomyopathy: Assessment by tricuspid annular velocities

Impaired right ventricular [RV] function can occurred in patients with left ventricular [LV] dysfunction. Tissue Doppler derived tricuspid annular velocities [TAV] permits assessment of systolic and diastolic RV function. The current study aimed to identify the cause of LV dysfunction whether idiopathic cardiomyopathy [DCM] or ishemic cardiomyopathy [ICM] on the basis of RV dysfunction type assessed by TAV. Fifty seven patients with LV ejection fraction <45% and dilated both ventricles were subgrouped according to the finding of coronary angiography into 30 patients with normal coronaries [DCM group], 15 patients with left coronary artery disease [CAD] [ICM[L] group] and 12 patients with proximal right CAD in addition [ICM[LR]] group]. Fourteen control subjects were also studied. Beside the routine echocardiographic assessment of LV and RV functions, peak systolic[s[m]] and peak early [E[m]] and late diastolic [A[m]] TAV were recorded. RV systolic dysfunction was defined as TA S[m] <10 cm/sec, while RV diastolic dysfunction was defined as TA E[m]/A[m] <1 Patients of DCM and ICM were matched regarding the global LV dysfunction [p>0.05]. ICM groups showed more frequent electrocardiographic Q wave, regional wall motion abnormalities, abnormal LV filling and RV systolic and diastolic dysfunction [TA S[m] <10cm/sec and TA E[m]/A[m] <1].While DCM group showed RV systolic dysfunction only [TA S[m] <10 cm/sec and TA E[m]/A[m] >1] [p<0.001]. Optimized detection of ICM [sensitivity 100%, specificity 100% and accuracy 100%] was achieved depending on the presence of TA E[m]/A[m]8.2 cm/sec could discriminate ICM[L] from ICM[LR] with sensitivity 100%, specificity 100% and accuracy 100%.In the presence of systolic dysfunction of both ventricles, the salient feature of ICM as compared to DCM is the TA derived RV diastolic dysfunction. In addition the marked RV systolic dysfunction in ICM favour left and right CAD