Relation Between RR Intervals and Early Diastolic Mitral Annular Velocities in Atrial Fibrillation

BACKGROUND AND OBJECTIVES: Irregular RR intervals in atrial fibrillation (AF) make beat-to-beat changes in left ventricular (LV) systolic performance. Early diastolic mitral annular velocity (E') is one of the well-established parameters for evaluating LV diastolic function. The relation between RR intervals and E's is unknown. The aim of this study was to observe the influence of continuous changes in RR interval on the parameter for diastolic function in AF. SUBJECTS AND METHODS: Echocardiography was performed in 117 patients with AF. E' was adjusted for the effect of pre-preceding RR interval (RR-2) using the logarithmic equation between RR-2 and E'. The logarithmic equation between adjusted E' and preceding RR interval (RR-1) was calculated. RESULTS: The slope in the relation between RR-1 and E' varied from -2.5 to 2.6. The slope was lower (more likely negative) in patients with higher ratio of early diastolic mitral flow velocity (E) to E' (r=-0.21, p=0.023), ischemic heart disease (IHD, r=0.21, p=0.026), and higher systolic blood pressure (r=-0.19, p=0.046). When patients were divided into these 3 groups on the basis of slope, the lowest slope group (0.57, n=39). The slope with regards to the relationship between RR-2 and E' also varied from -3.4 to 3.1. CONCLUSION: Changes in RR intervals had variable effects on E's according to clinical variables in AF.

Relationship Between RR Intervals and Early Diastolic Mitral Annulus Velocities in Atrial Fibrillation Patients Who do not Have Significant Valvular Diseases

BACKGROUND AND OBJECTIVES: Irregular RR intervals in atrial fibrillation (AF) results in beat to beat changes in hemodynamical parameters. Early diastolic mitral annulus velocity (E') is one of the parameters that represent diastolic function of the left ventricle (LV). In this study, we have investigated the effects of continuous changes of systolic functions in AF on the diastolic functions of the LV. SUBJECTS AND METHODS: E' (35-40 beats) was recorded in 31 AF patients that did not have significant valvular heart diseases. The relationships between preceding RR intervals (RR-1) or pre-preceding RR intervals (RR-2) and E's were obtained using a logarithmic function. RESULTS: Slopes between RR-1 and E' varied from -1.62 to 1.04 in total coordinates. In the logistic regression analysis patients with negative slopes were found to have a larger left atrial size than patients with positive slopes (5.5+/-0.67 cm vs. 4.9+/-0.56 cm, p=0.02). Slopes were negatively related with mean RR intervals in the Pearson correlation analysis (r=-0.40, p=0.028). Slopes between RR-2 and E' were also variable and were not associated with other parameters. CONCLUSION: Beat to beat changes in systolic functions derived from irregular RR intervals in AF had variable effects on diastolic functions among patients. The relationship between RR-1 and E' was associated with LA sizes and mean RR intervals.

Association of New Parameters Derived from Relation between RR intervals and Left Ventricular Performances with Heart Failure in Patients with Atrial Fibrillation and Normal Systolic Function

BACKGROUND AND OBJECTIVES: Heart failure (HF) may occur in atrial fibrillation (AF) patients with a normal left ventricular (LV) systolic function if the diastolic function is impaired. The association of new parameters from the relationship between the preceding RR interval (RR-1) and LV outflow peak ejection velocity (Vpe) with systolic function has been reported. The aim of this study was to observe whether these parameters were associated with HF in AF patients with a normal systolic function. SUBJECTS AND METHODS: AF patients with a normal systolic function were divided into two groups according to the presence (n=16) or absence (n=30) of a history of HF. From the logarithmic equation between RR-1 and Vpe, the slope, Vpe at RR-1 second (Vpe-1), and Slope/Vpe-1 were calculated. RESULTS: Patients with a history of HF were older (p=0.037) and tended to more frequently have hypertension (p=0.063) than those with no history of HF. The ejection fractions were similar between the two groups. In the coordinates with RR-1 from 0.6 to 1 second, the slope tended to be steeper (p=0.074) and slope/Vpe-1 was higher in patients with a history of HF (p=0.011). The Vpe-1 was similar between the two groups (p=0.66). A multiple forward logistic regression analysis showed that slope/Vpe-1 was the only independent variable associated with the occurrence of HF. Slope/Vpe-1 was related with aortic regurgitation, HF history, and the interventricular septal thickness in a multiple stepwise regression analysis. CONCLUSION: New parameters from the relationship between the RR intervals and LV performances were associated with the occurrence of HF in AF patients with a normal systolic function. This finding suggests that these parameters may be related with the LV diastolic function.

Assessment of Left Ventricular Diastolic functions in Elderly Patients with Pulmonary congestion and in Asymptomatic Elders

BACKGROUND: The recent studies shows that LV relaxation abnormalities are the important factors of heart failure in elders. To determine the association between LV diastolic functions and heart failure, we assessed LV diastolic functions in elderly patients with pulmonary congestion and in asymptomatic elders by using pulsed doppler echocardiography. METHODS: In order to assess LV diastolic function, we performed pulsed doppler echocardiography to elderly patients with pulmonary congestion and asymptomatic elders from Mar.2001 to Sep.2001. The following parameters were used as indices of LV diastolic function; Mitral E wave(E), Mitral A wave(A), Deceleration time(DT), Isovolumic relaxation time(IVRT), Systolic pulmonary venous flow(PVs), Diastolic pulmonary venous flow(PVd). RESULTS: In elderly patients groups, there was significant increase in deceleration time compared with asymptomatic elders(255.83+/-54.41 vs 210.80+/-48.53, p<0.05). There was significant increase in isovolumic relaxation time in elderly patient group compared with asymptomatic elders(123.06+/-25.07 vs 98.78+/-15.12, p<0.01). Although there was no significant difference, decreased E/A ratio and increased PVs/PVd were noted in both groups. CONCLUSIONS: The results shows that the impairments of LV diastolic function were noted in both groups. Especially DT and JVRT were significant increase in elderly patient group with pulmonary congestion. Therefore these parameters, such as DT, IVRT, can be helpful as predictive indices of diastolic heart failure in elders.

Pulsed doppler echocardiographic analysis of pulmonary venous flow in congenital heart diseases with left-to-right shunt

No abstract available.

Effects of Percutaneous Transluminal Coronary Angioplasty(PTCA) on Left Ventricular Diastolic Filling in Patients with Coronary Artery Disease; Assessed by Pulsed Doppler Echocardiography

To determine the effect of percutaneous transluminal coronary angioplasty on the left ventricular diastolic filling in patients with coronary artery disease, diastolic filling was serially examined before, early(within 2 days) and late(5~15 days) after PTCA using pulsed Doppler echocardiography in 14 patients(12 unstable angina; 2 stable angina). The Control group was consisted of 20 normal persons with similar age and sex distribution. The left anterior descending artery was dilated in 10 patients, the right coronary artery in 3 patients, and the circumflex artery in 1 patient. Peak velocity of early diastolic rapid inflow(E), peak velocity of late diastolic inflow (A), A/E ratio, and deceleration time of E wave were measured by pulsed Doppler echocar diography. 1) LVangiogram was performed in 10 patients, and showed normal wall motion in 7 cases and regional hypokinesia in 3 cases. Delta area decreasing rate was 59+/-10%, and LVEDP was 11+/-4 mmHg. 2) A/E ratio was greater in patient group(1.00+/-0.28) than in normal control (0.64+/-0.10) (p<0.05). There was no significant difference in A and E values between two groups. 3) A/E ratio decreased significantly from 1.00+/-0.28(pre-PTCA) to 0.85+/-0.24 (late post-PTCA) (p<0.01), but there was no significant change at early post-PTCA(0.94+/-0.32). Deceleration time also decreased significantly from 213+/-56 msec(pre-PTCA) to 177+/-34 msec (late post-PTCA) (p<0.05), but there was no significant change at early post-PTCA (199+/-34 msec). In conclusion, there was impairment of left ventricular diastolic filling in patients with coronary artery disease which gradually improved after PTCA, and this result probably is related to post-ischemic "stunned" myocardium.

Assessment of Left Ventricular Diastolic Function and Effect of Calcium Channel-Blocking Agent on Diastolic Function by Pulsed Doppler Echocardiography in Patients with Hypertrophic Cardiomyopathy

The symptoms of hypertrophic cardiomyopaty frequently result from impaired left ventricular relaxation, abnormal left ventricular filling, and decreased compliance of left ventricle in spite of normal systolic function. Several studies have suggested that the assessment of transmitral flow velocity waveform with pulsed Doppler echocardiography in patients with hypertrophic cardiomyopathy provide a noninvasive and clinically useful expression of left ventricular diastolic performance. In this study, pulsed Doppler echocardiography was used to measure diastolic indices from transmitral flow velocity waveform and thereby to assess left ventricular diastolic function in 20 patients with hypertrophic cardiomyopathy (14 septal hypertrophy, 3 apical hypertrophy, and 3 concentric hypertrophy). The diastolic indices to measure are isovolumic relaxation time(IVRT), deceleration time(DT), pressure half time(PHT), deceleration of early diastolic flow(DEF), EF slope, peak flow velocity in early diastole(PFVE), peak flow velocity during atrial systole(PFVA), and PFVE/PFVA ratio. The diastolic indices obtained from patients were compared with those in 20 age-matched control subjects without heart disease. The relationship between left ventricular wall thickness index(Th Index) and diastolic indices were evaluated. In addition, the effect of calcium channel-blocking agent on left ventricular diastolic function were evaluated. The results were as follows ; 1) There were no significant differences in RR interval, BP, end-systolic left ventricular dimension, and end-diastolic left ventricular dimension, but significant differences in interventricular septal thickness, posterior wall thickness, and left atrial dimension between hypertrophic group and control group. 2) The systolic index(ejection fraction) showed no significant difference between hypertrophic group and control group. 3) All diastolic indices except PFVA showed significant differences between hypertrophic group and control group. 4) Th Index did not showed a significant correlation with the diastolic indices except PFVE/PFVA. 5) There were no significant changes in RR interval, BP end-systolic left ventricular dimension, end-diastolic left ventricular dimension, left atrial dimension, and ejection fraction between medication and drug withdrawal. IVRT significantly increased after drug withdrawal. But other diastolic indices showed no significant changes after drug withdrawal. According to above results the assessment of left ventricular diastolic function by pulsed Doppler echocardiography was a clinically useful method in detecting diastolic dysfunction in patients with hypertrophic cardiomyopathy. Calcium channel-blocking agent may have beneficial effect in improving left ventricular diastolic function in patients with hypertrophic cardiomyopathy.

Early Doppler Echocardiographic Determination of Left Ventricular Diastolic Filling Defect In Adult Onset Diabetes Mellitus

To determine the early diagnostic parameters of the left ventricular diastolic filling defect in the uncontrolled adult onset diabetes mellitus, 86 diabetics were evaluated from the left ventricular inflow velocity pattern using pulsed Doppler echocardiography compared with normal 21 subjects. The diabetics were divided into 3 groups according to the presence or absence of background diabetic retinopathy(RE or coexisting cardiovascular diseases(group I : 34 cases without RE, group II : 24 cases with RE, group III : 28 cases with CVD). RE was thought to be having microangiopathy, but the cases with persistant massive proteinuria were excluded in this study. The left ventricular inflow velocity patterns were recorded from the apical approach. Peak velocity of the rapid filling phase(PFVE), that in the atrial systole(PFVA), E/A ratio, acceleration time(AT), deceleration time(DT), acceleration rate(ATR) and deceleration rate(DTR) were measured in the left ventricular inflow patterns. The results were ; 1) PFVE, AT and ATR in group I(56.26+/-12.21mm/sec, 70.91+/-14.98msec, 858.5+/-247mm/sec2), group II(51.91+/-14.35mm/sec, 64.84+/-14.98msec, 855.7+/-248.5mm/sec2) and group III(50.07+/-12.45mm/sec, 67.59+/-17.46msec, 817.5+/-266.8mm/sec2) were not significantly changed(p>0.05) compared to the controls(50.24+/-8.24mm/sec, 66.19+/-10.98msec, 784.5+/-221mm/sec2). 2) PFVA and DT in group I(51.21+/-14.86mm/sec, 156.2+/-23.42msec) and group II(64.26+/-13.93mm/sec, 64.84+/-14.13msec) were significantly increased(p0.05). 3) E/A ratio was significantly decreased in group II(0.82+/-0.21) and III(0.75+/-0.23) compared to the controls(1.19+/-0.25, p0.05) was noted. 4) DTR was also decreased in group II(311.9+/-95mm/sec2, p<0.05) and group III(297.7+/-125.8mm/sec2, p<0.05) compared to the controls(370.2+/-88mm/sec2) and group I(379.8+/-126mm/sec2). In conclusion, left ventricular diastolic filling defect in adult onset diabetics could be determined by using a various parameters of the pulsed Doppler echocardiography, which were closely related with diabetic retinopathy(RE). And DT and PFVA could be used as good parameters for early determination of the left ventricular diastolic filling defect in diabetics even without microangiopathy.

Noninvasive Evaluation of Left Ventricular Diastolic Function in Patients with Ischemic Heart Disease: Reconstruction of Transmitral Flow Rate and Filling Volume Curve with M-Mode, 2-Dimensional and Doppler Echocardiography

To evaluate the disturbed left ventricular diastolic filling by pulsed Doppler echocardiography in patients with ischemic heart disease who have normal systolic function, 117 subjects (50 angina patients with, 39 myocardial infarction patients with, 28 control subjects without significant coronary arterial narrowing) underwent echocardiographic examination one day before coronary arteriography. Beside analyzing trasmitral flow velocity curve, reconstruction and quantitative analysis of left ventricular filling rate and filling volume curves were made from Doppler trasmitral flow velocity curve, 2-Dimensional mitral annulus diameter and M-Mode mitral valve motion. From reconstructed left ventricular filling rate, filling fraction during early rapid filling or half diastolic rate, ratio of early to atrial peak filling rate, filling fraction during early rapid filling or half diastolic period and diastolic time interval(esp. T1/2 from peak early filling rate to its half valve)were measured. Angina and myocardial infarction group had significantly lower normalized peak early filling rate(4.9+/-0.6, 4.8+/-1.2 vs 6.0+/-1.1 DFV/sec, P<0.005), ratio of early to atrial peak filling rate(103.6+/-29. 4120.6+/-3.5 VS 175.5+/-55.0%, P<0.005), filling fraction during early diastolic period(46.2+/-5.0, 44.4+/-12.6 VS 54.3+/-6.8%, P<0.005) and filling fraction during half diastolic period(56.3+/-5.8, 55.4+/-14.1 VS 66.6+/-7.7%, P<0.005) than those of control group. Angina and myocardial infarction group had significantly higher normalized peak atrial filling rate(4.9+/-1.4, 5.0+/-2.0 VS 3.5+/-0.9 DFV/sec, P<0.005), prologed normalized T1/2 (12.5+/-3.0, 12.0+/-4.0 VS 9.8+/-2.2%, P<0.005) and delayed isovolumic relaxation time(81.7+/-7.8, 95.0+/-13.6 VS 74.3+/-6.9msec, P<0.005) than those of control group. Affecting factors to pseudonormalize left ventricular filling rate and filling volume curves in myocardial infarction group were mitral regurgitation, left ventricular aneurysm and severe impairment of systolic function. In 13 angina group patients who had undergone coronary angioplasty, no difference were found in any noninvasive diastolic filling parameters before and immediately(24 hours and 5 days) after the procedure. Thus, abnormal patterns of left ventricular filling occur in patients with ischemic heart disease and near normal global systolic function. The decreased peak early filling rate and early filling fraction occuring during rapid filling and the increased peak atrial filling rate occuring in late diastolic suggest that the patients with ischemic heart disease have impaired early diastolic filling. These diastolic filling abnormalities are unimproved 24 hour and 5 days after succesful coronary angioplasty. These diastolic filling parameters from left ventricular filling rate and filling volume curves provide useful noninvastive hemodynamic indices for assessment of left ventricular diastolic filling in patients with ischemic heart disease.

Reconstruction of the Transmitral Flow Rate Curve with M-Mode,2-Dimensional and Doppler Echocardiography -Validation Study-

To validate ventricular diastolic phase parameters of reconstructed transmitral flow rate curve by M-mode, 2-dimensional and pulsed Doppler Echocardiography, these parameters were compared with same parameters by left ventriculography. The study population was 22 patients who received both coronary arteriography and echocardiographic examination. Transmitral flow rate curve and left ventricular filling volume curve were reconstructed from transmitral flow velocity curve by pulsed Doppler, mitral annulus diameter by two diameter by two dimensional and diastolic motion of both mitral leafltes by M-mode echocardiography. From left ventriculography, left ventricular filling volume curve and transmitral flow rate curve were made using area-length method by Sandler and Dodge. From trasmitral flow fraction, 1/2 diastolic time filling fraction, normalized peak filling volume, 1/3 diastolic time filling fraction, 1/2 diastolic time fraction, normalized peak early filling rate and ratio of early to late peak filling rate were measured. Correlation between same parameters derived from echocardiography and left ventriculography were observed. 1) Total diastolic filling volume:correlation coefficient r=0.47, P<0.05. 2) 1/3 diastolic time filling fraction:correlation coefficient r=0.90, P<0.001. 3) 1/2 diastolic time filling fraction:correlation coefficient r=0.80, P<0.001. 4) Normalized peak early filling rate:correlation coefficient r=0.57, P<0.01. 5) Ratio of early to late peak filling rate:correlation coefficient r=0.85, P<0.001. Therefore, left ventricular diastolic phase parameters of reconstructed transmitral flow rate curve using, M-mode, 2-dimensional and pulsed Doppler echocardiography seems to be useful for the noninvasive evaluation of the left ventricular diastolic function.

The Usefulness of the Doppler Echocardiography in Patient with Atrial Septal Defect: Detection of Shunt Flow and Measurement of Qp/Qs Ratio

For the determination of the usefulness of the pulsed Doppler echocardiographic diagnosis of ASD. We evaluated 185 children with congenital heart disase by subxiphoid approach. ASD was diagnosed when abnormal flow was recorded in right atrium. ASD was proved by surgery in 33 of 185 children with congenital heart disease, and all children had sugical correction of their heart deformities. On pulsed Doppler echocardiographic exmination, abnormal flow was recorded in 32 of the 33 children with ASD and 3 of 152 children without ASD. This pulsed Doppler echocardiographic diagnosis of ASD by abnormal flow in right atrium has sensitively of 97% and specificity of 98%. High correlation was found between the estimates of Qp/Qs ratio by Doppler and Fick method(r=0.90, P<0.01). So we concluded that pulsed Doppler echocardiographic diagnosis of ASD was specific and sensitive method and careful pulsed Doppler echocardiographic examination may avoid the unnecessary cardiac catheterizetion in patients with ASD.

Left Ventricular Diastolic Filling in Dilated Cardiomyopathy: Pulsed Doppler Echocardiographic Study

Abnormal left ventricular diastolic properties have been reported in dilated cardiomyopathy (DC). Characteristics of transmitral flow were analysed in 37 patients with DC and 29 age matched normal subjects by pulsed Doppler echocardiography. Peak flow velocity of early diastole(PFVE, E), atrial systole (PFVA, A), E/A and deceleration rate of early diastolic flow (DEF) were measured from mitral Doppler spectrum. The extent of mitral regurgitation (MR) was determined by mapping method in the left atrium. Significant mitral regurgitation was founded in 27 out of 37 patients. Three distinct transmitral flow velocity patterns were demonstrated. Ten Patients without significant MR(27%, group 1), PFVE(58+/-17 cm/s), PFVA(73+/-17 cm/s) and E/A (0.94+/-0.4) were significant different from normal subjects (73+/-11 cm/s, 61+/-11 cm/s, 1.22+/-0.26, P<0.025, P<0.005, P<0.05, respectively). In contrast 17 patients with significant MR(46%, group 2) showed higher E (89+/-24 cm/s), lower A(52+/-19 cm/s), higher E/A (1.83+/-0.6) and DEF (596+/-149 cm/s2) than group 1 patients. Remained 10 cases (27%, group 3) had higher single peak flow (104+/-25 cm/s) with higher DEF and significant MR. In conclusion, abnormalities of left ventricular filling are detected in dilated cardiomyopathy without MR but not in DC with MR by Doppler echocardiography. The presence of MR, which augments early diastolic filling, may mask abnormal diastolic filling properties of DC.

Determination of Pulmonary to Systemic Flow Ratio and Prediction of Pulmonary Arterial Pressure in Children by Pulsed Doppler Echocardiography

The purpose of this study is to evaluate pulsed Doppler echocardiographic method (PD) for the measurement of pulmonary to systemic flow ratio (QP/Qs) and pulmonary arterial pressure in children. We studied 32 children with left to right shunt who had undergone cardiac catheterization, 11 children who had heart diseases without shunt and 14 normal children. Velocity time intergral (VTI) was calculated by triangulated meansurement [1/2(maximum blood velocityxejection time)]. Doppler blood flow was calculated from the equation : Doppler blood flow=VTIxcross sectional areaxheart rate. The following Doppler time intervals and ratio of intervals were also measured : preejection period(PEP), acceleration time(AT), ejection time (ET), PEP/AT, PEP/ET and AT/ET. Qp/Qs measured by PD was 1.09+/-0.15 (mean+/-SD) in children with no shunt and normal children. A high correlation was found between Fick and Doppler-derived Qp/Qs in children with left to right shunt (r=0.87). All the children with Qp/Qs less than 1.5 showed no significant discrepancy between two methods. The best correlation with pulmonary arterial pressure was achieved by the PEP/AT (r=0.84 vs systolic pressure). Sensitivity and specificity of PEP/AT for predicting pulmonary arterial hypertension were 79% and 95%, respecitively. In conclusion, it is thought that determination of Qp/Qs and prediction of pulmonary arterial pressure in children by PD is a useful, noninvasive method and triangulated measurement may be used as a simple and easy method for the measurement of Qp/Qs.

OBSERVATION OF HEART DIASTOLIC FUNCTION USING PULSED DOPPLER ECHOCARDIOGRAPHY FOR CHRONIC HEART FAILURE AND INTERFERENCE OF TREATMENT USING AMRINONE / 重庆医科大学学报

China-made amrinone (AMR) was orally administered to 10 patients with chro- nic congestive heart failure(CHF) for 72 hours, its mitral valve blood flow spectral shift was observed by pulsed Doppier echocardiograp hy(PDE). We found that peak A decreased, and peak A/peak E ratio decreased significantly. It suggested that AMR could improve left ventricular diastolic function. Early diastolic drag acceleration increased, it is one index of left ventricular diastolic function, its elevation suggested that left ventricular diastolic function had some improvement. These observation suggested that AMR could improve left ventricular diastolic function for hypertensive heart disease, coronary artery disease, congestive cardiom-yopathy with limited left ventricular diastolic function