Detection of Cerebral High-Intensity Transient Signals by NeoDoppler during Cardiac Catheterization and Cardiac Surgery in Infants.

There is a risk of gaseous and solid micro-embolus formation during transcatheter cardiac interventions and surgery in children with congenital heart disease (CHD). Our aim was to study the burden of high-intensity transient signals (HITS) during these procedures in infants. We used a novel color M-mode Doppler (CMD) technique by NeoDoppler, a non-invasive ultrasound system based on plane wave transmissions for transfontanellar continuous monitoring of cerebral blood flow in infants. The system displays CMD with 24 sample volumes and a Doppler spectrogram. Infants with CHD undergoing transcatheter interventions (n = 15) and surgery (n = 13) were included. HITS were manually detected based on an "embolic signature" in the CMD with corresponding intensity increase in the Doppler spectrogram. Embolus-to-blood ratio (EBR) defined HITS size. A total of 1169 HITS with a median EBR of 9.74 dB (interquartile range [IQR]: 5.10-15.80 dB) were detected. The median number of HITS in the surgery group was 45 (IQR: 11-150), while in the transcatheter group the median number was 12 (IQR: 7-24). During cardiac surgery, the highest number of HITS per hour was seen from initiation of cardiopulmonary bypass to aortic X-clamp. In this study we detected frequent HITS and determined the feasibility of using NeoDoppler monitoring for HITS detection.

Left atrial inflow propagation velocity derived by color M-mode Doppler in acute heart failure.

Left atrial (LA) inflow propagation velocity from the pulmonary vein (LAIF-PV) has been proposed as a novel measure of LA reservoir function and is associated with pulmonary capillary wedge pressure in critically ill patients. However, data on LAIF-PV in acute heart failure (AHF) are lacking. We sought to examine the feasibility of measuring LAIF-PV and evaluate clinical and echocardiographic correlates of LAIF-PV in AHF. In a prospective cohort study of adults hospitalized for AHF, we used color M-mode Doppler of the pulmonary veins to obtain LAIF-PV in systole. Among 142 patients with appropriate images and no more than moderate mitral regurgitation, LAIF-PV measures were feasible in 76 patients (54%) aged 71 ± 14 years, including 68% men with left ventricular ejection fraction (LVEF) 38% ± 13. Mean LAIF-PV was 24.2 ± 5.9 cm/s. In multivariable regression analysis adjusted for age, sex, systolic blood pressure, heart rate, body mass index, New York Heart Association class, LA volume and LVEF, the only independent echocardiographic predictors of LAIF-PV were right ventricular (RV) S' [ß 0.46 cm/s per cm/s (95% CI 0.01-0.91), p = 0.045] and tricuspid annular plane systolic excursion (TAPSE) [ß 0.28 cm/s per mm (95% CI 0.02-0.54), p = 0.039]. Notably, LAIF-PV was not significantly correlated with measures of LV function, LA function or E/e'. In conclusion, LAIF-PV was measurable in 54% of patients with AHF, and lower values were associated with measures of impaired RV systolic function but not LV or LA function.

Cardiac Function in Infants Born to Mothers With Gestational Diabetes　- Estimation of Early Diastolic Intraventricular Pressure Differences.

Background: This study compared the myocardial performance of infants born to mothers with gestational diabetes mellitus (IGDM) and without GDM (controls) under the new GDM definitions. Methods and Results: The subjects consisted of 36 IGDM and 39 control infants. GDM diagnosis was based on oral glucose tolerance test during pregnancy or the presence of diabetes prior to the current pregnancy. Between-group infant cardiac function was determined and compared using 2-D speckle tracking analysis, intraventricular pressure difference (IVPD) and IVP gradient (IVPG), using color M-mode Doppler imaging. IVPD and IVPG were higher in IGDM than in the controls, particularly the mid-apical IVPG. The global circumferential strain (GCS) and endocardial GCS were higher in IGDM than in controls. Increased maternal glycated hemoglobin was correlated with reduced transmural and epicardial GCS in the IGDM. Maternal maximum fasting blood sugar had a mild, positive correlation with IVPD and IVPG. Conclusions: Ventricular sucking force, measured as the IVPD, IVPG, and endocardial GCS, were higher in IGDM than in the controls. A hyperglycemic environment during pregnancy leads to impaired cardiac performance in IGDM, compared with control infants. IGDM might have favorable systolic and diastolic cardiac performance due to cardiac metabolic adaptations occurring before poor glucose control causes impaired cardiac performance.

Altered spatial distribution of the diastolic left ventricular pressure difference in heart failure.

BACKGROUND: The left ventricle fills in early diastole because of a progressive intraventricular pressure difference (IVPD) that extends from the left atrium to the left ventricular (LV). The aim of this study was to test the hypothesis that in patients with symptomatic heart failure (HF) regardless of LV ejection fraction (EF), an increase in left atrial (LA) pressure maintains early diastolic filling because of a preserved IVPD from the left atrium to the mid left ventricle, while the IVPD from the mid left ventricle to the apex is diminished because of reduced LV suction. METHODS: One hundred fifty-one patients with HF (50 with HF with preserved EF [HFpEF; EF ≥ 50%] and 101 with HF with reduced EF [HFrEF; EF < 50%]) and 28 normal controls were prospectively enrolled. The IVPDs from the left atrium to the LV apex (total IVPD), the left atrium to the mid left ventricle (basilar IVPD), and the mid left ventricle to the apex (apical IVPD) were determined using color M-mode Doppler echocardiographic data to integrate the Euler equation. The propagation of early diastolic filling was also assessed by color M-mode Doppler. RESULTS: The mean LV EF was 0.63 ± 0.07 in patients with HFpEF, 0.32 ± 0.09 in those with HFrEF, and 0.64 ± 0.06 in controls. Peak early diastolic transmitral flow velocities (E) were similar among the groups, and basilar IVPDs were maintained in the HFpEF and HFrEF groups (HFpEF, 1.59 ± 0.62 mm Hg; HFrEF, 1.49 ± 0.75 mm Hg; controls, 1.80 ± 0.61 mm Hg; P = NS, analysis of variance). However, apical IVPDs were decreased in both HF groups (HFpEF, 1.18 ± 0.56 mm Hg [P < .01 vs controls]; HFrEF, 0.87 ± 0.48 mm Hg [P < .01 vs controls]; controls, 1.65 ± 0.62 mm Hg), resulting in decreased total IVPDs in patients with HF (HFpEF, 2.55 ± 0.80 mm Hg [P < .01 vs controls]; HFrEF, 2.16 ± 0.80 mm Hg [P < .01 vs controls]; controls, 3.17 ± 0.91 mm Hg). E/e' ratios were increased in patients with HF, consistent with elevated LA pressure. In patients with HF, E was correlated with basilar IVPD but not with apical IVPD, whereas propagation of the filling was correlated with the apical IVPD but not with the basilar IVPD. CONCLUSIONS: In patients with HFpEF and those with HFrEF, apical IVPDs were reduced while basilar IVPDs were maintained by elevated LA pressure, resulting in preserved E.

New echocardiographic parameter of aortic stiffness and atherosclerosis in patients with coronary artery disease: aortic propagation velocity.

BACKGROUND: In this study, a novel echocardiographic parameter in the evaluation of the presence of coronary artery disease (CAD) and aortic stiffness, aortic propagation velocity, was measured and compared with other conventional aortic stiffness parameters such as aortic strain and aortic distensibility. Also, the relation between aortic propagation velocity and carotid intima media thickness was evaluated. METHOD AND RESULTS: A total of 51 patients with CAD and 42 patients with normal coronary arteries as a non-CAD group were included in the study. Aortic propagation velocity was significantly lower in the CAD group (p<0.001). A statistically significant relation was detected between aortic propagation velocity and the maximum, mean, and overall carotid intima media thickness values for right and left carotid arteries (p<0.001). There was a statistically significant relation between aortic propagation velocity, aortic strain, and aortic distensibility (r=0.556, p<0.001 and r=0.483, p<0.001 respectively). CONCLUSION: Aortic propagation velocity is a novel and simple echocardiographic parameter of aortic stiffness which is feasible for non invasive cardiovascular risk stratification and selection of high risk individuals for CAD.

Measurement of Left Ventricular Diastolic Function with Color M-mode Echocardiography in Patients with Acute Coronary Syndrome

BACKGROUND: Color M-mode doppler echocardiography has been suggested as a new noninvasive technique for assessing left ventricular diastolic function. The present study was performed to define the feasibility and value of color M-mode echocardiography for the assessment of left ventricular diastolic function in patients with acute coronary syndrome. METHODS: Thirty six patients with acute myocardial infarcion and twenty three patients with unstable angina were included (M/F=41/18, 61+/-12.2 years). Doppler study was performed using ATL HDI-3000 within 24 hours after the attack. In color M-mode study, ROP was measured with 'Front wave method' and 'Baseline shift method'. The patients were grouped into three groups based on E/A ratio and deceleration time (DT) in transmitral flow and S/D ratio in pulmonary venous flow; Group I=Normal pattern (E/A>1, S/D>1, DT>140 ms), Group II=Impaired relaxation pattern (E/A140 ms) and Group III=Pseudonormal/Restrictive pattern (E/A>1.5, S/D0.05). CONCLUSION: The ROP seems not to reflect the diastolic function in acute coronary syndrome, although it is measurable with the 'Front wave method' in most cases. The measurement of the ROP with 'Baseline shift method' is not feasible in the patients with acute coronary syndrome.

Evaluation of Left Ventricle Diastolic Function by Color M-Mode Doppler Echocardiography in Coronary Artery Disease

PURPOSE: The aims of this study were to evaluate the usefulness of the propagation velocity (Vp) measured by transthoracic color M-mode Doppler in patients with coronary artery disease and compare Vp with conventional diastolic function index using transmitral and pulmonary vein flow. METHODS: Study subjects were classified into two groups according to the presence of coronary artery disease (CAD): 44 subjects (M:F=22:22, mean age 63+/-12 yrs) with CAD (AMI; n=13 , unstable angina; n=5, stable angina; n=26); 31 normal subjects (M:F=13:18, mean age 43+/-15 yrs). Vp of early flow into left ventricular cavity measured by color M-mode Doppler was proposed as an index of left ventricular diastolic function. Vp was compared with conventional diastolic function index. RESULTS: 1. Vp in CAD patients (32.8+/-9.1 cm/sec) was lower than control (63.6+/-14.1 cm/sec)(p>0.01). Among CAD patients, Vp in CAD patients (30.1+/-8.6 cm/sec) with left ventricular hypertrophy (LVH) was lower than Vp in CAD patients without LVH (35.9+/-8.9 cm/sec)(p>0.01). 2. Vp was correlated with left ventricular ejection fraction (r=0.602, p>0.01), with D wave of pulmonary vein flow (r=0.540, p>0.01) and with E/A velocity ratio of mitral inflow (r=0.517, p>0.01) and negatively correlated with left ventricular mass index (r=-0.576, p>0.01). CONCLUSION: The propagation velocity measured by color M-mode Doppler is a useful index for evaluation of diastolic function of left ventricle in the patients with coronary artery disease.

Differential Findings of Color M-mode Doppler Echocardiography according to the In-hospital Congestive Heart Failure Following Actue Myocardial Infarction

BACKGROUND: Abnormalities of the left ventricular diastolic function can be classified by pulsed Doppler echocardiography, but sometimes it may be difficult to differentiate normal diastolic function from pseudonormalization. Heart failure caused by increased left ventricular filling pressure is rather associated with pseudonormalization or restrictive pattern than normal pattem or relaxation abnormality. We investigated the usefulness of color M-mode Doppler echocardiographic indexes in differentiating normal relaxation from pseudonormalization after acute myocardial infarction. METHOD: Echocardiographic examination including color M-mode Doppler was performed in 44 patients with acute myocardial infarction between 10 and 14 days after attack. 34 patients without in-hospital congestive heart failure(CHF) were assigned as group I, and 10 patients with in-hospital CHF as group II. Flow propagation slope(FPS), time difference(TD) between the occurrence of peak flow velocity in the apical region and at the mitral tip, and normalized time difference(nTD) by mitral and apical distance were measured with color M-mode Doppler echocardiography. RESULTS: FPS was lower in group II(group I, 42.0+/-20.6cm/sec vs group II, 27.8+/-8.0cm/ sec , p=0.065). Both groups had similar TD and nTD. FPS was compared in patients with E/ A ratio of mitral inflow greater than 1(22 patients of group I and 7 patients of group II). Patients with E/A) 1 in group II had significantly lower FPS(group I, 52.1+/-17.5cm/sec vs group II, 31.0+/-7.4cm/sec ; p(0.01). CONCLUSION: FPS was significantly decreased after acute myocardial infarction in patients with in-hospital CHF compared with patients without in-hospital CHF, even when E/A ratio of mitral inflow was greater than 1. Therefore, FPS was an useful index in differentiating normal relaxation from pseudonormalization.

Evaluation of Left Ventricular Diastolic Function by Color M-mode Doppler Echocardiography Using Baseline Shifted First Aliasing Limit Technique

BACKGROUND: Pulsed Doppler measurement of transmitral flow has been widely used to assess the left ventricular relaxation abnormality noninvasively in patients with failing heart. However pulsed Doppler-derived indices are affected by multiple factors, including active relaxation and distensibility of the left ventricle, the pressure gradient between the left ventricle and atrium, and altered loading condition. The purpose of this study is to assess the role of new index, the rate of propagation of left ventricular peak filling flow in early diastole using color M-mode Doppler for the evaluation of left ventricular diastolic function. METHOD: The study group comprised 41 patients(24 males, 17 felames, mean age: 56+/-12). The clinical diagnosis were angina pectoris 32, acute myocardial infarction 3, peripheral arterial obstructive disease 2 and atypical chest pain 4. We measured rate of propagation(ROP) and propagation ratio of peak early filling flow by color M-mode Doppler echocardiography using baseline shifted first aliasing limit technique and compared with pulsed Doppler measurements of transmitral flow. RESULTS: 1) Pulsed Doppler-derived indices of mitral flows were as below. The maximal velocity of E wave was 65.4+/-21.3cm/sec in control group, 54.3+/-7.9cm/sec in group I patients(p<0.05 versus control group) and 70.9+/-15.2cm/sec in group II patients(p<0.01 versus group I). The maximal velocity of A wave was 70.0+/-20.9cm/sec in control group, 78.6+/-3.8cm/sec in group I patients and 60.0+/-14.1cm/sec in group II patients(p<0.01 versus group I). The E/A ratio was 1.01+/-0.42 in control group, 0.69+/-0.10 in group I patients(p<0.05 versus control group) and 1.19+/-0.16 in group II patients(p<0.01 versus group I). The deceleration time was 166.7+/-36.3msec in control group, 202.9+/-17.0msec in group I patients(p<0.01 versus control group) and 160.0+/-10.0msec in group II patients(p<0.01) versus group I). 2) The rate of propagation was 145.0+/-83.4cm/sec in control group, 50.0+/-13.2cm/sec in group I patients(p<0.01 versus control group) and 59.9+/-26.0cm/sec in group II patients(p<0.01 versus control group). 3) The propagation ratio was 2.27+/-1.29cm/sec in control group, 0.93+/-0.25cm/sec in group I patients(p<0.05 versus control group) and 0.86+/-0.36cm/sec in group II patients(p<0.01 versus control group). CONCLUSION: Analysis of filling flow propagation by color M-mode Doppler is an easy and noninvasive method for evaluation of left ventricular diastolic function and may be an additional tool to pulsed Doppler measurement of transmitral flow, especially in differentiation between normal and pseudonormal, but care must be taken in interpretation because of overlapping of values.

Diastolic Dysfunction of Left Ventricle during Transient Myocardial Ischemia : Usefulness of Color M-mode Doppler Echocardiography

BACKGROUND: Left ventricular diastolic dysfunction may precede systolic dysfunction and play a major role in producing the signs and symptoms of congestive heart failure. Ischemic heart disease can cause impairment of left ventricular filling without any alteration in systolic function so it is very important to evaluate relationship of left ventricular diastolic dysfunction and ischemic heart disease. The purpose of this study is to investigate left ventricular diastolic dysfunction during transient myocardial ischemia caused by balloon occlusion. METHODS: We prospectively studied 20 patients(11 males and 9 females, mean age : 58.5+/-5.9 years) who had been undergone coronary angiography and confirmed significant luminal stenosis(> or =75%)in proximal or middle portion of left anterior descending artery. After coronary angiography, percutaneous transluminal coronary angioplasty were performed all patients. We measured early propagation slope of left ventricular inflow, time difference(TD) between occurrence of peak velocity in the apical region and at the mitral tip and normalized TD(nTD) which dividing TD by the distance of mitral opening to apical region using color M-mode Doppler echocardiography, peak earaly diastolic transmitral inflow velocity(E), peak velocity during atrial contraction(A), E to A ratio, acceleration time of E wave and deceleration time of E wave using pulsed wave Doppler echocardiography, left ventricular end diastolic pressure using left heart catheterization. A color M-mode Doppler echocardiography, pulsed wave Doppler echocardiography and left ventricular end diastolic pressure were recorded before, during 30sec, 60sec & 90sec and after 60sec & 180sec balloon occlusion. RESULTS: Early propagation slope of left ventricular inflow was significantly decreased during 30sec & 60sec balloon occlusion and significantly increased after 60sec & 180sec balloon occlusion, respectively (64.45+/-28.23cm/sec, 39.37+/-11.77cm/sec, 32.78+/-11.77cm/sec, 51.86+/-19.78cm/sec, 65.05+/-29.99cm/sec, p0.05). CONCLUSIONS: These data suggest that transient myocardial ischemia can cause left ventricular diastolic dysfunction and color M-mode Doppler echocardiography is very sensitive diagnostic method to detect early diastolic dysfunction compare to other echocardiographic diastolic indices.

Comparison of Mitral Doppler Flow, Flow Propagation Velocity and Peak Filling Rate between Patients with Normal and Systolic LV Dysfunction in Presence of Atrial Fibrillation

BACKGROUND: Methods for evaluating left ventricular diastolic function have been used exclusively in cardiac patients in sinus rhythm and have not been applied to atrial fibrillation because of large cycle variation in flow velocities and absence of atrial contraction. The utility of these rnethods in atrial fibrillation is unknown, especially M-rnode Doppler echocardiography and automatic border detection method. METHODS: Left Ventricular Normal group(LVN group, Ejection fraction> 40%) of 21 patients(mean age 67 years old, 12 men, 9 women) and Left Ventricular Dysfunction group (LVD group, EF ( 40%) of 15 patients(mean age 64 years old, 11 men, 4 women) were studied. We measured parameters in pulsed Doppler recordings of rnitral flow velocity and the flow propagation velocity in color M-mode recording of mitral flow, and peak filling rate from automatic border detection system. Measurements were averaged over 10 cardiac cycles. RESULTS: Mean heart rates were not different in both population(LVN 79+/-18/min, LVD 83+/-16/min). Left ventricular diastolic dimension were more dilated LVD group than LVN group(5.7+/-1.0crn, 4.6+/-0.7cm p < 0.05) but left atrial dimension were similar(4.4+/-0.8cm, 4.3+/-0.7cm). Deceleration time was significantly shortened in LVD group(158.4+/-24.4ms vs. 180.4+37.6ms, p < 0.05) but other parameters of mitral pulsed Doppler recording such as IVRT, acceleration time, acceleration rate and deceleration rate were not different. Flow propagation velocities were significantly decreased in LVD group(41.7+/-14.9cm/s vs. 53.0+/-11. 9cm/s, p < 0.05). Peak filling rates of automatic border detection system were significantly decreased in LVD group(3.4+/-1.2 EDV/s vs 5.4+/-1.1 EDV/s, p< 0.001). CONCLUSION: Echocardiographic measurements of diastolic function via color M-mode Doppler and autornatic border detection may be useful in presence of atrial fibrillation as sinvs rhythm.

Diastolic Function Evaluation in Systemic Arterial Hypertension : A Color M-mode Doppler and Doppler Echocardiographic Analysis

BACKGROUND: Several recent studies have demonstrated that left ventricular diastolic dysfunction is major cause of congestive heart failure and may precede systolic dysfunction or without left ventricular hypertrophy in most patients with systemic arterial hypertension. The purpose of this study is to evaluate left ventricular diastolic function in patients with systemic arterial hypertension compared with normal control group using color M-mode Doppler and Doppler echocardiographic studies. METHODS: From October 1994 to August 1995. 53 patients(18 men and 35 women, mean age : 56.1±12.6 years) with essential hypertension and 30 subjects age-matched nomal controls(13 men and 17 women, mean age 55.9±12.3 years) were included in this study. We measured the early propagation slope of LV inflow by color M-mode Doppler Echocadiography and the peak velocities of E and A wave, E/A tatio, deceleration time of E wave, isovolumic relaxation time by Doppler echocardiography. We also studied left ventricular diastolic function in patients with hypertension who were divided two group(Group I : hypertension with left ventricular hypertrophy, Group II : hypertension without left vetricular hypertrophy). RESULTS: 1) Early propagation slope of LV inflow was significantly decreased in patients with hypertension compared with normal control group(57.43±17.15m/secs vs 69.87±12.71m/secs, p 0.05), whereas deceleration time of E wave was showed increasing tendency in patients with hypertension empared with normal control group(196.57±37.07m/secs vs 189.33±41.35m/secs, p>0.05). 3) Early propagation slope of LV inflow was not significantly different between Group I and Group II, but showing decreasing tendency in Group I compared with Group II(54.72±14.65m/sec vs 60.16±18.96m/sec, p>0.05). Peak velocity of E wave and peak velocity of A wave and E/A ratio and deceleration time were not significantly different between Group I and Group II but peak velocity of E wave and E/A ratio were showed decreasing tendency in Group I(0.65±0.19m/sec vs 0.73±0.22m/sec, 0.86±040 vs 1.04±0.44, p>0.05), whereas peak velocity of A wave and deceleration time of E wave were showed increasing tendency in Group I(0.80±0.20m/sec vs 0.74±0.18m/sec, 199.38±46.45m/secs vs 196.89±24.76m/secs, p>0.05). Only isovolumic relaxation time was significatly increased in Group I compared with Group II(150.63±44.75m/secs vs 120.34±19.77m/secs, p < 0.05). CONCLUSION: Left ventricular diastolic dysfunction may precrede systolic or without left ventricular hypertrophy in patients with systemic arterial hypertension. An early diagnosis of left ventricular diastolic dysfunction, color M-mode Doppler echocardiography and Doppler echocardiography were useful diagnostic stools.