Non-invasive cardiac assessment in beta-thalassaemia major.

Iron deposition in the heart occurs in beta-thalassaemia major and contributes to cardiac dysfunction. Eighteen patients with beta-thalassaemia major were assessed clinically and had non-invasive investigations. They were young (15.5 +/- 3.6 years). Two patients had clinical heart failure. Doppler echocardiography demonstrated higher transmitral peak flow velocity in early and late diastole compared with controls (e: p<0.05, a: p<0.01). Transtricuspid peak late diastolic flow velocity was higher in patients (p<0.005). Isovolumic relaxation time was shortened (p<0.001). Pulmonary venous flow velocity was higher in diastole than systole (S: 0.51 +/- 0.11 m/s, D: 0.62 +/- 0.08 m/s). Reversal of pulmonary venous flow during atrial systole was seen in eight patients. These diastolic filling abnormalities did not significantly change with blood transfusion. Left ventricular ejection fraction was normal in patients. Two patients had cardiomegaly on chest X-ray. In beta-thalassaemia with iron overload, there is a restrictive pattern of diastolic dysfunction. This is not altered by recent blood transfusion. Left ventricular function remains relatively intact.

The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography.

Left ventricular diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. An impaired relaxation pattern identifies patients with early stages of heart disease, and appropriate therapy may avert progression and functional disability. Pseudonormalization is a transitional phase between abnormal relaxation and restrictive physiology and signifies increased filling pressure and decreased compliance. In this phase, reducing preload, optimizing afterload, and treating the underlying disease are clinically helpful. A restrictive physiology pattern identifies advanced, usually symptomatic disease with a poor prognosis. Therapeutic intervention is directed toward normalizing loading conditions and improving the restrictive filling pattern, although this may not be feasible in certain heart diseases. Finally, many patients have left ventricular filling patterns that appear indeterminate or mixed. In these cases, clinical information, left atrial and left ventricular size, pulmonary venous flow velocity, and alteration of preload help assess diastolic function and estimate diastolic filling pressures.

Doppler evaluation of left and right ventricular diastolic function: a technical guide for obtaining optimal flow velocity recordings.

Doppler mitral flow velocities and related variables are used to assess left (LV) and right ventricular filling and, indirectly, ventricular diastolic function. Three abnormal ventricular filling patterns (impaired relaxation and pseudonormal and restrictive physiology) are recognized in patients with various heart diseases and have been related to alterations in LV diastolic properties and filling pressures. More recently, these variables have been used to assess the hemodynamic effects of drug therapy or heart surgery and prognosis in patients with restrictive and dilated cardiomyopathies. Despite these encouraging results, widespread clinical use of these Doppler techniques has been hampered by difficulties in obtaining accurate and reproducible measurements from Doppler flow velocity recordings. This is due, in part, to an underappreciation of factors such as cardiac filling mechanics, Doppler examination principles, and ultrasound machine settings, which can markedly affect the quality of the flow velocity recordings. The purpose of this article is to provide the technical information for performing a systematic and comprehensive Doppler evaluation of LV diastolic function that can be used on a routine basis. This information includes discussing the different flow velocity recordings required for a Doppler assessment of LV diastolic function, their proper recording technique, and the common technical pitfalls.

Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation.

BACKGROUND: Respiratory variation of > or = 25% in mitral E velocity is a characteristic Doppler echocardiographic feature in constrictive pericarditis. However, a subset of patients with constriction do not exhibit the typical respiratory change, most likely because of marked increase in the left atrial pressure, and preload reduction may unmask the respiratory variation. METHODS AND RESULTS: In 12 patients with surgically confirmed constrictive pericarditis who had < 25% respiratory variation in mitral E velocity during an initial preoperative examination, the Doppler study was repeated after an attempt to decrease left ventricular filling pressure. At baseline, mean mitral E velocity was similar after inspiration and expiration (0.81 +/- 0.24 and 0.84 +/- 0.21 m/s, respectively). On repeat Doppler examination, with the patient in a head-up tilt or sitting position the decrease in mitral E velocity with inspiration (0.61 +/- 0.13 m/s) was significant (P < .004), whereas it did not change significantly with expiration. The mean percent respiratory change in E velocity was 5 +/- 7% at baseline and 32 +/- 28% with preload reduction. Eight (75%) of the 12 patients developed respiratory variation of > or = 25%. CONCLUSIONS: When the respiratory variation in Doppler mitral E velocity is blunted or absent during the evaluation of suspected constrictive pericarditis, repeat Doppler recording of mitral flow velocities after maneuvers to decrease preload is recommended to unmask the characteristic respiratory variation in mitral E velocity.

Clinical and echocardiographic follow-up after aortic valve reconstruction with bovine or autologous pericardium.

Eighty-six patients, mean age 29 +/- 15 years, underwent aortic valve reconstruction with bovine or autologous pericardial tissue. Mean clinical follow-up was 35 months. Echocardiographic data were assessed in 65 patients with follow-up > or = 6 months. There were two in-hospital and three late deaths. Warfarin was not given, and no thromboembolic events occurred. Five (6%) patients needed reoperation because of severe aortic regurgitation. Peak aortic valve gradients remained low (26 +/- 14 mm Hg for the bovine group and 16 +/- 16 mm Hg for the autologous group). One patient is awaiting surgery for aortic stenosis after 76 months. Leaflet thickening at latest follow-up was marked in six (9%) patients. Left ventricular dimensions normalized postoperatively and showed only insignificant increase during follow-up. This technique is a promising alternative to valve prosthesis in selected patients; however, longer follow-up is necessary to assess long-term results.

Evaluation of reference systems for quantitative wall motion analysis from three-dimensional endocardial surface reconstruction: an echocardiographic study in subjects with and without myocardial infarction.

Six relevant computer-implemented reference systems for three-dimensional quantitative assessment of left ventricular wall motion abnormalities were compared with visual wall motion analysis of two-dimensional images. Endocardial borders were traced in three apical echocardiographic views at end-diastole and end-systole in 10 patients with myocardial infarction and 5 healthy subjects, and three-dimensional reconstruction of endocardial surfaces was performed. End-diastolic and end-systolic surfaces were aligned in a common axis system depending on the reference system, and systolic wall motion was assessed at 1,024 points on the endocardial surface. The localization of abnormal wall motion was displayed in bull's-eye maps, and the area was determined as a percentage of total endocardial area. For each reference system, the segmental concordance between three-dimensional computerized and visual assessment was determined. The best agreement between computerized and visual analysis was obtained with a reference system based on wall motion towards the major ventricular axis, whereas the poorest result was obtained using the center of left ventricular cavity as reference. Correlation between the estimated area of wall motion abnormality and visually determined wall motion score index was best using the aligned center of mitral valve plane as reference (r = .92).

Surgery for rheumatic mitral regurgitation in patients below twenty years of age. An analysis of failures.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair is less stable in rheumatic than in degenerative disease. This failure rate is inversely related to the age of the patient. Based on our clinical experience, we selected the group of patients with the worst results for this study: (i) rheumatic, (ii) age 20 or under, (iii) pure mitral regurgitation (MR), and, (iv) no aortic disease. MATERIALS AND METHODS: Between 1988 and 1995, 83 consecutive patients complied with these characteristics. No patient was excluded. Replacement (MVR) was performed in 26 and repair (MRp) in 57 (69%). RESULTS: There was one hospital death (1%) with an actuarial survival at 48 months of 74.8% +/- 19% for MVR and of 97.9% +/- 2.1% at 78 months for MRp. There were no thromboembolic events. Reoperation was required in one MVR (4%) and in 21 MRp (37%), within same admission in six, within three months in eight, under one year in three, and beyond in four cases. Severe MR appeared in five further cases. No statistical difference was found between the preoperative clinical data, operative findings and surgical maneuvers of those patients with successful and unsuccessful repair. The rate of failure was similar after Kay (14/29) and Duran (12/28) annuloplasty. All patients showed a rapid decrease in left ventricular dimensions. Early failures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension than the other groups. Late failures were more related to progression of the rheumatic process. No clear relationship between rheumatic activity and failure rate was found. CONCLUSION: Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology in the developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might prevent its further progression, avoiding the problems of secondary chordal elongation.

Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis.

BACKGROUND: Dilated cardiomyopathy is an important cause of morbidity and mortality among patients with congestive heart failure. Hemodynamic and prognostic characterization are critical in guiding selection of medical and surgical therapies. METHODS AND RESULTS: A cohort of 102 patients with the clinical diagnosis of dilated cardiomyopathy who underwent echocardiographic examination between 1986 and 1990 was identified and followed up through July 1, 1991. Patients with moderate or severe symptoms had lower indices of systolic function and greater left atrial and right ventricular dilation. Mitral inflow Doppler signals were characterized by a restrictive left ventricular filling pattern. In multivariate logistic regression analysis, deceleration time, ejection fraction, and peak E velocity were independently associated with symptom status. Over a mean follow-up of 36 months, 35 patients died. Kaplan-Meier estimated survival at 1, 2, and 4 years was 84%, 73%, and 61%, respectively, and was significantly poorer than that of an age- and sex-matched population. The subgroup with an ejection fraction < 0.25 and deceleration time < 130 milliseconds had a 2-year survival of only 35%. The subgroup with ejection fraction < 0.25 and deceleration time > 130 milliseconds had an intermediate 2-year survival of 72%, whereas patients with an ejection fraction > or = 0.25 had 2-year survivals > or = 95% regardless of deceleration time. In multivariate analysis, ejection fraction and systolic blood pressure were independently predictive of subsequent mortality. Mitral deceleration time was significant in univariate analysis. CONCLUSIONS: In patients with the clinical diagnosis of dilated cardiomyopathy, markers of diastolic dysfunction correlated strongly with congestive symptoms, whereas variables of systolic function were the strongest predictors of survival. Consideration of both ejection fraction and deceleration time allowed identification of subgroups with divergent long-term prognoses.

Diagnostic role of Doppler echocardiography in constrictive pericarditis.

OBJECTIVES: This study was conducted to assess the diagnostic role of Doppler echocardiography in constrictive pericarditis. BACKGROUND: It has been observed that patients with constrictive pericarditis have a characteristic Doppler pattern of respiratory variation in ventricular filling and central venous flow velocities. However, the observation was based on a small number of patients with known diagnosis. METHODS: We reviewed the echocardiographic features of 28 patients (21 men and 7 women; mean age +/- SD 55 +/- 15 years) with suspected constrictive pericarditis who underwent exploratory thoracotomy or pericardiectomy. RESULTS: At operation, constrictive pericarditis was diagnosed in 25 patients, restriction in 1 and normal pericardium in 2. Of the 25 patients with constriction, correct preoperative Doppler diagnosis was made in 22 (88%) and Doppler echocardiography showed restriction in 3. In two patients with a normal pericardium, Doppler features were consistent with constriction in one patient and were normal in the other. In the one patient with restriction, Doppler echocardiography showed restriction. In 19 patients with surgically proved constriction, repeat Doppler study after pericardiectomy showed normal findings in 14 and restriction in 5. Twelve of the 14 patients with normalized Doppler findings became asymptomatic, whereas all 5 with restrictive Doppler features remained symptomatic. CONCLUSIONS: Doppler echocardiography performed simultaneously with respiratory recording is highly sensitive for diagnosing constrictive pericarditis, and it appears to predict functional response to pericardiectomy.

Transient constrictive pericarditis: diagnosis by two-dimensional Doppler echocardiography.

Patients with constrictive pericarditis usually require pericardiectomy to relieve their symptoms. In some patients, however, constrictive pericarditis may resolve spontaneously or with medical treatment. Four patients with transient constrictive pericarditis are described in this report. Although the cause of pericarditis differed, all patients had a small to large amount of pericardial effusion, followed by symptoms, signs, and Doppler features typical of constrictive pericarditis. Symptomatic improvement occurred after treatment with some combination of nonsteroidal anti-inflammatory agents, corticosteroids, and antibiotics. The resolution of the symptoms paralleled the normalization of characteristic respiratory changes in Doppler flow velocities. The condition of our patients most likely was related to a transient inflammation (or thickening) of the pericardium due to viral, bacterial, or immunologically mediated pericarditis. Resolution of the thickened pericardium was documented by magnetic resonance imaging in one patient. Awareness of the possible transient nature of constrictive pericarditis in a subgroup of patients with constriction has important clinical implications when pericardiectomy is considered. The resolution of constrictive pericarditis can be documented by serial Doppler echocardiographic examination.

Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures.

OBJECTIVES: This study was conducted to investigate whether pulmonary venous flow variables measured by transthoracic Doppler ultrasound can help identify patients with elevated left ventricular end-diastolic or filling pressures, or both. BACKGROUND: A widened left atrial pressure A wave occurs when left ventricular end-diastolic pressure is increased. Increased duration of pulmonary venous flow reversal at atrial systole might therefore be a marker for elevated end-diastolic pressure. Decreased systolic pulmonary venous flow is shown to be related to increased left ventricular filling pressure in studies using transesophageal Doppler echocardiography. METHODS: Left ventricular pressures at late diastole were measured by fluid-filled catheters in 50 consecutive patients undergoing diagnostic cardiac catheterization. Pulmonary venous and mitral flow velocities were recorded by transthoracic pulsed Doppler ultrasound. RESULTS: Adequate recordings were obtained in 45 patients. Pulmonary venous flow reversal exceeding the duration of the mitral A wave predicted left ventricular end-diastolic pressure > 15 mm Hg with a sensitivity of 0.85 and a specificity of 0.79. This difference in flow duration correlated well with the increase in ventricular pressure (r = 0.70, p < 0.001) at atrial systole and the end-diastolic pressure (r = 0.68, p < 0.001). The systolic fraction of pulmonary venous flow was markedly decreased (< 0.4) in all patients with a pre-A pressure (left ventricular pressure before atrial systole) > 18 mm Hg. CONCLUSIONS: Pulmonary venous flow reversal exceeding the duration of the mitral A wave indicates an exaggerated increase in left ventricular late diastolic pressure. Pulmonary venous systolic fraction < 0.4 suggests markedly increased ventricular filling pressure.

Prognostic significance of Doppler measures of diastolic function in cardiac amyloidosis. A Doppler echocardiography study.

BACKGROUND: We have previously characterized the left ventricular diastolic filling abnormalities in cardiac amyloidosis by Doppler methods. The various filling patterns were shown to be related to the degree of cardiac amyloid infiltration. The purpose of this study was to determine the value of Doppler diastolic filling variables for assessing prognosis in cardiac amyloidosis. METHODS AND RESULTS: We performed pulsed-wave Doppler studies of the left ventricular inflow and obtained clinical follow-up data in 63 consecutive patients with biopsy-proven systemic amyloidosis. All patients had typical echocardiographic features of cardiac involvement. The patients were subdivided into two groups according to deceleration time: Group 1 (33 patients) had a deceleration time of 150 msec or less, indicative of restrictive physiology, and group 2 (30 patients) had a deceleration time of more than 150 msec. Of the 63 patients, 32 (51%) died during a mean follow-up period of 18 +/- 12 months. Of these deaths, 25 (78%) were cardiac deaths, and 19 of the 25 patients (76%) were from group 1. The 1-year probability of survival in group 1 was significantly less than that in group 2 (49% versus 92%, p less than 0.001). Bivariate analysis revealed that the combination of the Doppler variables of shortened deceleration time and increased early diastolic filling velocity to atrial filling velocity ratio were stronger predictors of cardiac death than were the two-dimensional echocardiographic variables of mean left ventricular wall thickness and fractional shortening. CONCLUSIONS: Doppler-derived left ventricular diastolic filling variables are important predictors of survival in cardiac amyloidosis.

Serial Doppler echocardiographic follow-up of left ventricular diastolic function in cardiac amyloidosis.

A spectrum of left ventricular diastolic filling abnormalities noted on Doppler echocardiography has been demonstrated in patients with cardiac amyloidosis. To determine how these filling abnormalities evolve over time and the significance of any change, serial pulsed wave Doppler studies of left ventricular inflow were performed over 12.6 +/- 4.9 months in 41 consecutive patients (36 men and 15 women, mean age 59 +/- 11 years) with typical two-dimensional echocardiographic features of cardiac involvement. The measurements were peak left ventricular inflow in early diastole (E) and atrial contraction (A) velocities, E/A ratio, deceleration time and isovolumetric relaxation time. Patients were classified by mean left ventricular wall thickness into an early group (less than 15 mm) of 24 patients and an advanced group (greater than or equal to 15 mm) of 17 patients. The total group showed an increased E/A ratio (1.7 +/- 0.9 versus 1.4 +/- 0.9, p = 0.009) and decreased deceleration time (164 +/- 57 versus 174 +/- 51 ms, p = 0.11) at follow-up compared with baseline study. The early group showed significant changes in the E/A ratio (1.6 +/- 1.0 versus 1.2 +/- 0.7, p = 0.001) between the two studies. Seven patients (29%) in the early group showed a change from an abnormal relaxation or "normal" pattern to one of restriction, coincident with increased symptoms in six of these patients. Fifteen (88%) of the 17 patients in the advanced group did not show significant changes in the measures during the follow-up study, but these patients already showed a restrictive pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

Variability of Doppler echocardiographic indexes of left ventricular filling in transplant recipients and in normal subjects.

This study examines the reproducibility and variability of pulsed wave Doppler versus continuous wave Doppler ultrasound indexes of left ventricular filling in cardiac allograft recipients and in normal subjects. The following indexes were studied: isovolumic relaxation time, pressure half-time, peak early mitral flow velocity, and peak mitral flow velocity after atrial systole. Intraobserver and interobserver variability were assessed by regression analysis. Individual components of variance (subject, reader, beat, day, and tracing) were estimated in a subset of five patients and five normal subjects, and estimated total variance defined for each group. Temporal (day-to-day) variability for 95% confidence was estimated for these patients and for normal subjects. Temporal variability in the group from which the subsets were drawn was measured from absolute and percent change in values on two occasions. Estimated and observed 95% confidence limits were compared. Intersubject variability was the largest component of variance in both transplant recipients and in normal subjects. For all indexes in transplant recipients (in the absence of rejection) and normal subjects, observed absolute mean differences (+/- 2 standard deviations) between values from recordings taken on two different days were larger than the 95% confidence limits estimated from the components of variance analysis. The observed 95% limits for transplant recipients versus normal subjects were as follows: isovolumic relaxation time, 20 msec versus 6 msec; pressure half-time, 16 msec versus 9 msec; peak early mitral flow velocity, 32 cm per second versus 17 cm per second; and peak mitral flow velocity after atrial systole, 28 cm per second versus 10 cm per second.(ABSTRACT TRUNCATED AT 250 WORDS)

Relation of pulmonary vein to mitral flow velocities by transesophageal Doppler echocardiography. Effect of different loading conditions.

It has previously been demonstrated that predictable changes occur in mitral flow velocities under different loading conditions. The purpose of this study was to relate changes in pulmonary venous and mitral flow velocities during different loading conditions as assessed by transesophageal echocardiography in the operating room. Nineteen patients had measurements of hemodynamics, that is, mitral and pulmonary vein flow velocities during the control situation, a decrease in preload by administration of nitroglycerin, an increase in preload by administration of fluids, and an increase in afterload by infusion of phenylephrine. There was a direct correlation between the changes in the mitral E velocity and the early peak diastolic velocity in the pulmonary vein curves (r = 0.61) as well as a direct correlation between the deceleration time of the mitral and pulmonary venous flow velocities in early diastole (r = 0.84). This indicates that diastolic flow velocity in the pulmonary vein is determined by the same factors that influence the mitral flow velocity curves. A decrease in preload caused a significant reduction in the initial E velocity and prolongation of deceleration time, and an increase in preload caused an increase in E velocity and shortening of deceleration time. An increase in afterload produced a variable effect on the initial E velocity and deceleration time and was dependent on the left ventricular filling pressure. The change in systolic forward flow velocity in the pulmonary vein was directly proportional to the change in cardiac output (r = 0.60). The pulmonary capillary wedge pressure correlated best with the flow velocity reversal in the pulmonary vein at atrial contraction (r = 0.81). Use of pulmonary vein velocities in conjunction with mitral flow velocities can help in understanding left ventricular filling.

Comprehensive Doppler assessment of right ventricular diastolic function in cardiac amyloidosis.

To assess right ventricular diastolic function in cardiac amyloidosis, pulsed wave Doppler ultrasound measurements of right ventricular inflow velocities and superior vena cava and hepatic vein flow velocities with respiratory monitoring were performed in 41 patients with primary systemic amyloidosis and two-dimensional echocardiographic features of cardiac involvement. Right ventricular diastolic function was abnormal in 31 (76%) of these patients, the major abnormality being a short deceleration time (less than 150 ms) in 21 (68%), suggesting restriction. In contrast, 7 (23%) of the 31 patients had a decreased ratio of early (E) and late (A) diastolic peak flow velocities and a prolonged deceleration time (greater than 240 ms), suggesting abnormal relaxation. The patients were classified into two groups on the basis of right ventricular free wall thickness: group 1, less than 7 mm and group 2, greater than or equal to 7 mm. Compared with normal values, group 1 showed an increased peak late flow velocity (44 +/- 19 versus 39 +/- 6 cm/s; p less than 0.01) and a decreased E/A velocity ratio (1.1 +/- 0.4 versus 1.5 +/- 0.3; p less than 0.01). Group 2 showed a markedly shortened deceleration time (151 +/- 37 versus 225 +/- 28 ms; p less than 0.01), characteristic of restriction. In the overall group, superior vena cava peak flow velocity was decreased in systole and increased in diastole and flow reversals during inspiration were increased compared with normal values. Hepatic venous flow velocities were similar to those in the superior vena cava except for larger flow reversals in the hepatic vein. Thus, in cardiac amyloidosis, right ventricular diastolic function is abnormal. There is a spectrum of right ventricular filling abnormalities and the restrictive filling pattern is seen only in the advanced stages of the disease.

Flow velocity acceleration in the left ventricle: a useful Doppler echocardiographic sign of hemodynamically significant mitral regurgitation.

Doppler echocardiography is a sensitive method to detect mitral regurgitation in patients with both native and prosthetic valves. However, estimates of the amount of mitral regurgitation remain semiquantitative, and even severe mitral regurgitation may be underestimated in the presence of markedly eccentric regurgitant jets or acoustic shadowing of the left atrium by mitral or aortic prostheses. This report describes the Doppler findings in 10 patients with severe native valve mitral regurgitation (angiographic grade III or IV) and in 15 patients with severe bioprosthetic mitral regurgitation that required valve replacement. An increase in peak mitral flow velocity above normal values was seen in eight of 10 patients with severe native valve mitral regurgitation (greater than or equal to 130 cm per second) and 11 of 15 patients with severe prosthetic valve mitral regurgitation (greater than or equal to 210 cm per second). One of 10 patients with a native valve and four of 15 patients with a bioprosthetic valve appeared to have only a localized left atrial systolic flow disturbance, incorrectly suggesting that the mitral regurgitation was mild. However, in all patients with severe mitral regurgitation, a low velocity (less than 100 cm per second) flow signal could be recorded in the left ventricle that was directed toward the mitral valve in systole. This flow signal showed a gradual increase in velocity as the sample volume was moved toward the mitral valve, with an abrupt further increase on entry into the left atrium. This signal was continuous with antegrade mitral flow and had the same orientation as mitral regurgitation recorded by continuous wave technique from the apex. A similar flow signal was not recorded in the left ventricle of any individual in a control group of 30 patients who had no mitral regurgitation or who had angiographic grade I or II mitral regurgitation. These findings suggest that acceleration of left ventricle flow toward the mitral valve in systole is only recorded when there is hemodynamically significant mitral regurgitation that is approximately equal to angiographic grade III or IV. Recognition of this Doppler finding may help in the estimation of mitral regurgitation severity, especially in difficult diagnostic situations.

Characteristic Doppler echocardiographic pattern of mitral inflow velocity in severe aortic regurgitation.

In symptomatic severe aortic regurgitation, left ventricular diastolic pressure increases rapidly, often exceeding left atrial pressure in late diastole. This characteristic hemodynamic change should be reflected in the Doppler mitral inflow velocity, which is the direct result of the diastolic pressure difference between the left ventricle and left atrium. Mitral inflow velocity was obtained by pulsed wave Doppler echocardiography in 11 patients (6 men, 5 women: mean age 53 years) with severe symptomatic aortic regurgitation and compared with normal values from 11 sex- and age-matched control subjects. The following Doppler variables were determined: velocity of early filling wave (E), velocity of late filling wave due to atrial contraction (A), E to A ratio (E/A), deceleration time and pressure half-time. In severe aortic regurgitation, E and E/A (1.13 m/s and 3.3, respectively) were significantly higher (p less than 0.001) than normal (0.60 m/s and 1.5, respectively). Deceleration time and pressure half-time (117 and 34 ms, respectively) were significantly shorter (p less than 0.001) than normal (203 and 59 ms, respectively). Late filling wave velocity (A) was not statistically different in the two groups, although it tended to be lower in the patient group (0.39 versus 0.50 m/s). Diastolic mitral regurgitation was present in eight patients (73%). M-mode echocardiography of the mitral valve, performed in 10 patients, showed that only 3 (30%) had premature mitral valve closure. In symptomatic severe aortic regurgitation, the Doppler mitral inflow velocity pattern is characteristic, with increased early filling wave velocity (E) and early to late filling wave ratio (E/A) and decreased deceleration time of the E wave.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of Doppler indices of diastolic filling of the left ventricle: comparison with invasive hemodynamics in a canine model.

Doppler measurements of mitral flow velocity curves have been proposed as a method for characterizing diastolic filling of the left ventricle. Different velocity curves have been empirically described in different disease states and under differing loading conditions in humans, but relating these various Doppler parameters to hemodynamic measurements of ventricular diastolic properties has not been fully elucidated. The effect of differing loading conditions (preload reduction, preload increase, afterload increase) on the Doppler mitral flow velocity and high-fidelity left atrial-left ventricular pressures was examined in seven closed-chest, anesthetized dogs. Preload reduction by balloon inflation in the inferior vena cava resulted in significant decreases in E velocity (early diastolic velocity) from 0.39 +/- 0.09 m/sec to 0.29 +/- 0.10 m/sec (p less than 0.01) and prolongation of deceleration time from 131 +/- 18 msec to 165 +/- 60 msec (p less than 0.05). Preload increase by infusion of fluids resulted in a significant increase in E velocity from 0.39 +/- 0.09 m/sec to 0.49 +/- 0.10 m/sec (p less than 0.001) and shortening of the deceleration time from 131 +/- 18 msec to 95 +/- 15 msec (p less than 0.001). The effect of afterload increase was variable and was dependent upon the left atrial pressure. Significant but weak positive correlations were noted between E velocity and maximal left atrial-left ventricular pressure gradient (r = 0.47, p less than 0.001) and total change in left ventricular pressure (r = 0.68, p less than 0.001), with inverse relationships between the deceleration time and these parameters. There was no overall relationship between the time constant tau and the E velocity, but an inverse relationship emerged when the data were examined according to different filling pressures. These results indicate that none of the mitral velocity measurements should be directly equated with other measurements of diastolic function. However, distinct velocity curves emerged under differing loading conditions that help in interpreting the meaning of these curves.

Doppler characterization of left ventricular diastolic function in cardiac amyloidosis.

Sixty-four patients with primary systemic amyloidosis-53 with two-dimensional echocardiographic features of cardiac involvement (Group I) and 11 without cardiac involvement (Group II)--underwent Doppler echocardiographic assessment of left ventricular diastolic function. Pulsed wave Doppler recordings of left ventricular inflow velocities and pulmonary vein flow velocities with respiratory monitoring in these patients were compared with findings in a normal group. Patients in Group I showed striking abnormalities of left ventricular diastolic filling when classified into subgroups by mean left ventricular wall thickness: early greater than 12 but less than 15 mm; advanced greater than or equal to 15 mm. In early amyloidosis, relaxation was abnormal, with decreased peak early velocity (75 +/- 20 versus 86 +/- 16 cm/s; p less than 0.01), increased late velocity (71 +/- 22 versus 56 +/- 13 cm/s; p less than 0.01), decreased early to late velocity ratio (1.2 +/- 0.6 versus 1.6 +/- 0.5; p less than 0.01) and prolonged isovolumic relaxation time (87 +/- 15 versus 73 +/- 13 ms; p less than 0.01) compared with normal values. In advanced amyloidosis, there was a restrictive filling pattern with a markedly shortened deceleration time (148 +/- 50 versus 199 +/- 32 ms; p less than 0.001), decreased pulmonary vein peak systolic flow velocity (34 +/- 16 versus 54 +/- 12 cm/s; p less than 0.01) and increased diastolic flow velocity (55 +/- 20 versus 44 +/- 12 cm/s; p less than 0.01) compared with normal values. Group and the subgroup with early amyloidosis had similar flow velocity patterns. Thus, this study documents that in cardiac amyloidosis, a spectrum of diastolic filling abnormalities exists; the restrictive filling pattern is seen only in the advanced stages.