Recurrent giant longitudinal duodenal ulcer with massive hemorrhage in a Helicobacter pylori-negative patient.

A 67-year-old man, in whom a linear ulcer running from the duodenal bulb to the descending part had been noted 3 years previously, was admitted to our hospital because of abdominal pain and melena. Duodenoscopy revealed a bleeding giant longitudinal ulcer, which was more extensive than before. Tests for Helicobacter pylori (Hp) were negative. The ulcer was cured by endoscopic hemostasis and repeated blood transfusions. Attention must be paid to Hp-negative post-bulbar duodenal ulcers because of the frequent complications including hemorrhage.

Penetration by a giant gastric ulcer induced by a nonsteroidal anti-inflammatory drug.

A patient presented with penetration by a giant gastric ulcer resulting from treatment with a nonsteroidal anti-inflammatory drug. A test for Helicobacter pylori proved negative. Treatment with a combination of an inhibitor of gastric acid secretion and prostaglandin substitution therapy with misoprostol resulted in closure of the perforation and cicatrization of the gastric ulcer without the need for laparotomy.

Regional left ventricular myocardial contraction abnormalities and asynchrony in patients with hypertrophic cardiomyopathy evaluated by magnetic resonance spatial modulation of magnetization myocardial tagging.

Global left ventricular (LV) pump function is generally preserved in patients with hypertrophic cardiomyopathy (HCM). However, it is unknown whether regional myocardial contractility is impaired, especially in nonhypertrophied regions. The purpose of this study was to evaluate regional LV myocardial contraction in patients with HCM using magnetic resonance (MR) spatial modulation of magnetization (SPAMM) myocardial tagging. The study group comprised 20 patients with asymmetric septal hypertrophy (HCM group) and 16 age-matched normal patients (control group), and data were collected using transthoracic M-mode and 2-dimensional echocardiography, and MR SPAMM myocardial tagging. The systolic strain ratio, maximum systolic strain velocity, and time from end-diastole to maximum systolic strain (deltaT) in the anterior, ventricular septal, inferior and lateral regions for 2 LV short-axis sections at the levels of the chordae tendineae and papillary muscles were measured at 50-ms intervals by MR myocardial tagging. The end-diastolic anterior and ventricular septal wall thicknesses and LV mass index were significantly different between the HCM and control groups. The systolic strain ratio for all 4 walls, particularly the anterior and ventricular septal regions, was significantly lower in the HCM group. In the HCM group, the maximum systolic strain velocity was significantly lower and deltaT was significantly shorter for all 4 walls, particularly the anterior and ventricular septal regions. The standard deviation for the deltaT, calculated from the deltaT for the 8 regions of the 2 LV short-axis sections, was significantly greater in the HCM group. In conclusion, regional LV myocardial contraction is impaired in both hypertrophied and nonhypertrophied regions, and systolic LV wall asynchrony occurs in patients with HCM.

Effect of an acute increase in afterload on left ventricular regional wall motion velocity in healthy subjects.

We recorded left ventricular (LV) wall motion velocities before and after angiotensin II infusion by pulsed tissue Doppler imaging in 20 healthy subjects, and evaluated the responses of systolic and diastolic LV function along the long and short axes during an acute increase in afterload. Angiotensin II was administered intravenously to obtain a 30% increase in mean blood pressure. After angiotensin II infusion, LV end-systolic dimension and end-systolic circumferential wall stress increased significantly, and the percentage of LV fractional shortening decreased significantly. Peak first systolic LV wall motion velocity (Sw1 ) along the long axis decreased markedly compared with that along the short axis, and peak second systolic LV wall motion velocity (Sw2 ) along the short axis decreased significantly compared with that along the long axis. Early diastolic LV wall motion velocities along both the long and short axes decreased significantly, whereas atrial systolic LV wall motion velocity did not change. In conclusion, an acute increase in afterload caused a significant decrease in longitudinal fiber shortening during the isovolumic contraction phase (Sw1 along the long axis), circumferential fiber shortening during the ejection phase (Sw2 along the short axis), and LV relaxation during early diastole (early diastolic LV wall motion velocities along both axes) in healthy subjects. Pulsed tissue Doppler imaging may be useful for detecting the effect of various loading conditions on LV wall motion velocities along the long and short axes.

Pulsed tissue Doppler imaging of left ventricular systolic and diastolic wall motion velocities to evaluate differences between long and short axes in healthy subjects.

Our objective was to evaluate in healthy subjects the left ventricular (LV) wall motion velocities along the long and short axes by means of pulsed tissue Doppler imaging (TDI) to clarify the differences in the LV systolic and diastolic function between both axes. Wall motion velocities were recorded at the mid-wall portion of the middle site of the LV posterior wall in the parasternal long-axis view, and at the subendocardial portion of the middle site of the LV posterior wall in the apical long-axis view by pulsed TDI in 35 healthy subjects (mean age 26 +/- 10 years, mean heart rate 72 +/- 7 bpm). In all subjects, the LV pressure curve, its first derivative (dP/dt), the LV wall motion velocity, the phonocardiogram, and the electrocardiogram were simultaneously recorded. The systolic wave of the LV posterior wall motion velocity exhibited 2 peaks: the first and second systolic waves (Swl and Sw2, respectively). The diastolic wave also exhibited 2 peaks, the early diastolic and atrial systolic waves. The Swl along the long axis was greater than either the Sw1 and Sw2 along the short axis or the Sw2 along the long axis. The peak Sw1 along the long axis coincided with the peak dP/dt and was slightly earlier than the peak Swl along the short axis. The onset of Sw1 along the long axis coincided with the onset of the first heart sound. The Sw2 along the short axis was greater than that along the long axis. The early diastolic wave along the short axis was greater than that along the long axis, whereas the atrial systolic wave along the long axis was greater than that along the short axis. Thus, in healthy subjects, shortening of the longitudinal fibers predominated over that of the circumferential fibers during early systole, whereas shortening of the circumferential fibers predominated over the longitudinal fibers during the ejection phase. During diastole, the circumferential fibers predominated in the LV wall expansion at early diastole, whereas the longitudinal fibers predominated at atrial systole. In conclusion, pulsed TDI provided information that is useful in understanding the characteristics of LV wall motion along the long and short axes.

Left ventricular systolic wall motion velocities along the long and short axes measured by pulsed tissue Doppler imaging in patients with atrial fibrillation.

Pulsed tissue Doppler imaging was performed to measure systolic left ventricular (LV) posterior wall motion velocity along the long and short axes and to evaluate the relationships between the systolic variables and the maximum first derivative (peak dP/dt) of the LV pressure curve and the 2 preceding R-R intervals in 39 patients with atrial fibrillation (AF). The study group consisted of 22 patients with AF only, 17 patients with dilated or ischemic cardiomyopathy and AF, and 25 healthy control subjects in sinus rhythm. The systolic component of the LV posterior wall motion velocity was divided into the first (Sw1) and second (Sw2 ) systolic waves. The peak Sw1 along the long axis was greater than either that along the short axis or the peak Sw2s along the long and short axes in the control and AF-only groups. The peak Sw1 along the long axis was lower in the AF-only group than in the control group, and those along the short and long axes were lower in the dilated AF group than in the other groups. The peak Sw1 almost coincided with the peak dP/dt. The peak Sw1 along the long axis correlated closely with the peak dP/dt, and the ratio of the preceding R-R interval to the interval before the preceding ("prepreceding") R-R interval in both AF groups, particularly in the dilated AF group, and the slopes of their relationships were steeper in the dilated AF group than in the AF-only group. The peak Sw2 along the short axis was greater than that along the long axis in the control and AF-only groups. The peak Sw2 along the long axis was lower in the AF-only group than in the control group, and those along the short and long axes were lower in the dilated AF group than in the other groups. The peak dP/dt was lower and the LV end-diastolic pressure was higher in the dilated AF group than in the other groups. In conclusion, peak Sw1 along the long axis is useful for the evaluation of isovolumic myocardial LV contractility, and the interval-force relation and the Frank-Starling mechanism are important factors of beat-to-beat variability in systolic LV function in patients with AF.

Difference in the diastolic left ventricular wall motion velocities between aortic and mitral regurgitation by pulsed tissue Doppler imaging.

We evaluated the difference in the diastolic left ventricular (LV) wall motion velocity between chronic isolated aortic and mitral regurgitation (AR and MR, respectively) by recording subendocardial motion velocity patterns at the middle site of the LV posterior wall in the parasternal (along the short axis) and apical (along the long axis) long-axis views of the left ventricle with pulsed tissue Doppler imaging. We studied 33 patients with AR and 35 with MR, showing moderate to severe regurgitation, and 34 healthy controls (C). The end-diastolic LV dimension along the short axis was greater in the AR and MR groups than in the C group, and that along the long axis was greater in the AR group than in the MR and C groups. There were no significant differences in percent LV fractional shortening along the short axis among the 3 groups, whereas that along the long axis was significantly smaller in the AR group than in the MR and C groups. The peak early diastolic wall motion velocity (Ew) and the time to Ew from the aortic component of the second heart sound (S2 -Ew) along the long axis were significantly lower and longer, respectively, in patients with AR than in the 2 other groups. The Ew and S2 -Ew along both the short and long axes were significantly higher and shorter, respectively, in patients with MR than in the 2 other groups. The peak early diastolic velocity of the transmitral flow correlated positively with Ew along the short axis in all patients with AR and correlated positively with Ews along the long and short axes in all patients with MR. In conclusion, early diastolic LV filling was associated with expansion of the LV wall along the short axis but with decreased excursion along the long axis in patients with AR, whereas that in patients with MR was associated with expansion of the LV wall along both the long and short axes. Pulsed tissue Doppler imaging was useful for evaluation of diastolic LV function along the long and short axes in patients with diastolic LV volume overload.

Regional left ventricular wall motion abnormalities in myocardial infarction and mitral annular descent velocities studied with pulsed tissue Doppler imaging.

We evaluated global left ventricular (LV) systolic function from mitral annular systolic motion velocities measured by pulsed tissue Doppler imaging in patients with previous myocardial infarction (MI) and LV regional wall motion abnormalities. The subject group consisted of 45 patients with wall asynergies, 3 with ischemic cardiomyopathy, 8 with dilated cardiomyopathy, and 15 healthy control subjects. The peak systolic descent velocity (Sw) and the time from the electrocardiographic Q wave to the peak of the systolic wave (Q-Sw) were measured at 6 mitral annular sites obtained from 2-dimensional apical long-axis, 4-chamber, and 2-chamber echocardiograms; these variables were compared with the LV ejection fraction (EF) calculated from the left ventriculogram. The mean Sw at the sites corresponding to the infarct regions was significantly lower and the mean Q-Sw was significantly longer in the MI groups than in the control group. The mean Sw and Q-Sw at all 6 sites in the ischemic and dilated cardiomyopathy groups were significantly lower and longer, respectively, than those of the control group. There were significant correlations between the EF and the means of the Sw and Q-Sw values at the sites corresponding to the infarct regions in the MI groups. In the ischemic and dilated cardiomyopathy groups, significant correlations existed between the EF and the means of the Sw and Q-Sw values at all 6 sites. Thus the parameters obtained from mitral annular systolic motion velocities with pulsed tissue Doppler imaging reflect LV asynergy corresponding to the infarct regions in patients with MI, and global LV systolic function may be evaluated with these parameters.

Assessment of abnormal left atrial relaxation by transesophageal pulsed Doppler echocardiography of pulmonary venous flow velocity.

BACKGROUND: Several studies on left ventricular relaxation have been undertaken in the past; however, left atrial (LA) relaxation has not been fully evaluated. HYPOTHESIS: The purpose of this study was to assess abnormalities in LA relaxation by evaluating pulmonary venous flow velocity and interatrial septal motion using transesophageal echocardiography. METHODS: The subjects were 56 untreated patients in sinus rhythm, including 25 with previous myocardial infarction, 9 with hypertrophic cardiomyopathy, 11 with dilated cardiomyopathy, as well as 11 with chest pain syndrome as controls. Peak first systolic velocity (PVS1), peak atrial systolic velocity (PVA), and their time-velocity integrals (PVS1-I and PVA-I, respectively) were calculated from the pulmonary venous flow velocity. RESULTS: The PVS1 and PVS1-I correlated negatively with the maximum LA dimension and mean pulmonary capillary wedge pressure, and correlated positively with the amplitude of the interatrial septal motion during LA relaxation and percent fractional LA relaxation. The PVA and PVA-I did not correlate with the mean pulmonary capillary wedge pressure. There was a weak positive correlation between PVA and PVS1, and a close positive correlation between the ratio of PVA to PVS1 and mean pulmonary capillary wedge pressure. Multiple regression analysis indicated that the PVS1 was most closely related to percent fractional LA relaxation, followed by mean pulmonary capillary wedge pressure. CONCLUSION: The PVS1 determined from the pulmonary venous flow velocity is closely related to parameters of LA relaxation which may be determined by transesophageal M-mode echocardiography, and the ratio of PVA to PVS1 is useful for noninvasive evaluation of LA pressure.

Right heart flow dynamics after tricuspid valve annuloplasty. Characteristics and time course.

To evaluate the effect of tricuspid annuloplasty (TAP) on right heart flow dynamics, we analyzed tricuspid inflow velocity pattern, jugular venous pulse and color Doppler flow signal of tricuspid regurgitation (TR) before and after surgery in 16 patients who underwent TAP (TAP group). Cardiac rhythm was atrial fibrillation in all patients. Twelve patients with lone atrial fibrillation served as controls (AF group). Patients in the TAP group were studied before and serially after surgery with a mean follow-up period of 2.7 years. TAP was performed according to the modified De Vega technique in all patients. In a comparison of the most recent data in the TAP group and the data in the AF group, the maximum tricuspid inflow velocity was significantly increased, and both the deceleration time of the tricuspid inflow velocity wave and the y-h interval of the jugular venous pulse were significantly prolonged in the TAP group compared to the AF group. Immediately after surgery, in the TAP group, the area of the TR jet was markedly decreased, and the deceleration time of the tricuspid inflow velocity wave was significantly prolonged compared to those before surgery. The area of the TR jet was dramatically decreased and remained small during the follow-up period. Thus, TAP may produce mild tricuspid stenosis but may also confer sustained preventive effects against TR.

Difference in systolic motion velocity of the left ventricular posterior wall in patients with asymmetric septal hypertrophy and prior anteroseptal myocardial infarction. Evaluation by pulsed tissue Doppler imaging.

The left ventricular (LV) posterior wall in patients with asymmetric septal hypertrophy or prior anteroseptal myocardial infarction (A-MI) frequently demonstrates normal or supernormal motion to compensate for hypokinesis of the interventricular septum. This study evaluated the systolic motion velocity of the posterior wall in these conditions using a pulsed tissue Doppler imaging system. The study population consisted of 30 patients with hypertrophic cardiomyopathy (HC) and asymmetric septal hypertrophy, 25 with prior A-MI and 30 normal controls. The systolic excursion of the posterior wall was obtained by M-mode echocardiography. The endocardial motion velocities of the posterior wall were obtained by pulsed tissue Doppler imaging. The systolic excursion of the posterior wall was significantly greater in the A-MI and HC groups than in the control group, and was significantly greater in the A-MI group than in the HC group. The peak systolic velocity of the posterior wall was significantly lower in the HC group than in the control and A-MI groups, and the time from the electrocardiographic Q wave to the peak of the systolic wave of the posterior wall was significantly longer in the HC group than in the other groups. There were rough negative and positive correlations between the LV end-diastolic pressure and the peak systolic velocity and time from the Q wave to the peak of the systolic wave, respectively. In conclusion, LV myocardial contractility in HC patients was impaired when compared to A-MI patients despite similar posterior wall motion on the M-mode echocardiogram. Pulsed tissue Doppler imaging method may provide new insights and allow further evaluation of myocardial dysfunction.

Assessment of left ventricular systolic wall motion velocity with pulsed tissue Doppler imaging: comparison with peak dP/dt of the left ventricular pressure curve.

To assess the usefulness of the tissue Doppler imaging variables for the evaluation of left ventricular (LV) systolic function, we compared variables obtained by the pulsed Doppler method with the LV ejection fraction (%EF) and the maximum value for the first derivative of LV pressure (peak dP/dt). We examined 65 patients, including 15 patients with noncardiac chest pain, 15 with ischemic heart disease, 15 with dilated cardiomyopathy, 10 with hypertensive heart disease, and 10 with asymmetric septal hypertrophic cardiomyopathy. The subendocardial systolic wall motion velocity patterns were recorded for LV posterior wall and ventricular septum in the parasternal LV long-axis view. The peak dP/dt was significantly lower in the hypertensive heart disease, hypertrophic cardiomyopathy, and dilated cardiomyopathy groups. The peak systolic velocity was lower and the time from the electrocardiographic Q wave to the peak of the systolic wave for the posterior wall was longer in the hypertensive heart disease (5.9 +/- 0.5 cm/sec and 215 +/- 21 msec, respectively), hypertrophic cardiomyopathy (6.2 +/- 0.9 cm/sec and 217 +/- 17 msec, respectively), and dilated cardiomyopathy (5.2 +/- 0.8 cm/sec and 235 +/- 26 msec, respectively) groups than in the noncardiac chest pain (7.7 +/- 0.9 cm/sec and 187 +/- 24 msec, respectively) and the ischemic heart disease (7.6 +/- 0.8 cm/sec and 184 +/- 22 msec, respectively) groups. In all groups, the peak systolic velocity and the time from the electrocardiographic Q wave to the peak of the systolic wave for the posterior wall correlated directly and inversely, respectively, with the %EF (r = 0.59, p < 0.0001; r = -0.59, p < 0.0001) and the peak dP/dt (r = 0.75, p < 0.0001; r = -0.68, p < 0.0001). Both tissue Doppler variables for the ventricular septum did not correlate with the %EF but roughly correlated with peak dP/dt. We conclude that the systolic LV wall motion velocity parameters obtained by pulsed tissue Doppler imaging may be useful for noninvasive evaluation of global LV systolic function in patients with no regional asynergy.

Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation.

BACKGROUND: The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling. HYPOTHESIS: The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation. METHODS: We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm. RESULTS: Mean pulmonary capillary wedge pressure, V-wave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V-wave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy. CONCLUSION: Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.

Differences in transmitral flow velocity pattern during increase in preload in patients with abnormal left ventricular relaxation.

Changes in transmitral flow (TMF) and pulmonary venous flow (PVF) velocities during increases in preload were compared in patients with a higher peak atrial systolic velocity than peak early diastolic velocity (A/E > 1) for the TMF velocity to determine differences in hemodynamic response. Fifteen patients with dilated hearts, 22 with hypertrophied hearts and 15 control patients were studied. TMF and PVF velocities were recorded by transesophageal pulsed Doppler echocardiography before and during application of lower body positive pressure. The value for peak early diastolic velocity increased, while the isovolumic relaxation time decreased with increases in preload in all groups. The value for peak atrial systolic velocity decreased in the dilated-heart group, but increased in the hypertrophied-heart and control groups. The peak second systolic and early diastolic PVF velocities increased in the dilated- and hypertrophied-heart groups, but did not change in the control group. The peak atrial systolic PVF velocity and the difference in duration of the atrial systolic PVF and TMF velocities increased in the dilated- and hypertrophied-heart groups, and its changing rate was highest in the group with dilated hearts. These results suggest that both peak early diastolic and atrial systolic TMF velocities increase during increases in preload through the Frank-Starling mechanism in hypertrophied hearts. Furthermore, the left ventricular functional reserve was lower in the dilated-heart group. Thus, TMF and PVF velocities respond differently during increases in preload, depending on the underlying heart disease.

Right and left ventricular wall motion velocities as diagnostic indicators of constrictive pericarditis.

The purpose of this study was to examine the usefulness of pulsed tissue Doppler imaging for diagnosing constrictive pericarditis. Motion velocities of the ventricular septum (VS) and left ventricular (LV) posterior wall along the short axis, and those of the anterior right ventricular (RV) wall, VS, and LV posterior wall along the long axis were recorded using pulsed tissue Doppler imaging in 12 patients with constrictive pericarditis, who were diagnosed by cardiac catheterization, and also in 20 normal subjects. Peak early diastolic and atrial systolic velocities (Ew and Aw, respectively) were calculated, and the time between the aortic component of the second heart sound and the peak of the early diastolic velocity (IIA-Ew) was determined. The peak Ew and II A-Ew along the short and long axes were significantly higher and shorter, respectively, in the patient group than in the normal group. In the patient group, the motion velocity of the VS along the short axis showed a "backward" motion with a sharp and marked peak velocity immediately before Ew, or a biphasic early diastolic wave; a clear "downward" motion immediately after Ew was observed in the motion velocities of the anterior RV wall, VS, and LV posterior wall along the long axis. These distinctive backward and downward motions were not observed in any of the ventricular walls of the normal subjects. In conclusion, the early diastolic RV and LV wall motion velocity patterns along the short and long axes as measured by pulsed tissue Doppler imaging provide important information for the diagnosis of constrictive pericarditis.

Role of left atrial appendage in left atrial reservoir function as evaluated by left atrial appendage clamping during cardiac surgery.

We evaluated the role of left atrial appendage (LAA) in the left atrial (LA) reservoir function by assessing the changes in LA flow dynamics after LAA clamping during cardiac surgery. The subjects were 8 patients who had undergone coronary artery bypass grafting (CABG) and 7 who had undergone mitral valvular surgery due to mitral regurgitation. We recorded transmitral, pulmonary venous and LAA flow velocity patterns by intraoperative transesophageal pulsed Doppler echocardiography, monitoring LA pressure before and 5 minutes after LAA clamping. The maximal LAA area was significantly greater, and the peak late diastolic LAA emptying flow velocity was significantly lower before LAA clamping in the mitral regurgitation group than in the CABG group. In both groups, the peak early and late diastolic transmitral and pulmonary venous flow velocities significantly increased, and the peak second systolic pulmonary flow velocity significantly decreased during LAA clamping. There were no significant changes in heart rate and systemic systolic blood pressure during LAA clamping, whereas mean LA pressure and maximal LA dimension significantly increased in both the groups. The LA pressure-volume relation during ventricular systole shifted upward and to the left during LAA clamping, and the slope was steeper in the MR group than in the CABG group. We conclude that the LAA is more compliant than the LA main chamber, and plays an important role in LA reservoir function in the presence of LA pressure and/or volume overload.

Left ventricular diastolic properties of hypertensive patients measured by pulsed tissue Doppler imaging.

Examination of left ventricular (LV) diastolic dysfunction in hypertensive patients has been based on parameters obtained from the transmitral flow velocity during pulsed Doppler echocardiography. However, these parameters are affected by loading conditions. We evaluated LV diastolic function along the longitudinal and transverse axes by pulsed tissue Doppler imaging (TDI) in 50 hypertensive (HT) patients and 36 age-matched healthy volunteers (N). Transmitral flow velocity was recorded by pulsed Doppler echocardiography. LV posterior wall motion velocity along the longitudinal and transverse axes also was recorded by pulsed TDI. In both groups, peak early diastolic velocity of the LV posterior wall (Ew) along the transverse axis (N: 15.8+/-5.2 cm/s, HT: 12.2+/-4.4 cm/s) was higher than that along the longitudinal axis (N: 12.7+/-3.1 cm/s, HT: 9.5+/-3.3 cm/s). Peak atrial systolic velocity of the LV posterior wall (Aw) along the longitudinal axis (N: 9.1+/-1.8 cm/s, HT: 9.7 +/-2.6 cm/s) significantly exceeded that along the transverse axis (N: 8.0+/-2.2 cm/s, HT: 8.4+/-2.4 cm/s) in both groups. The Ews were lower and the Aws were higher along both axes in the patient group than in the control group. The time intervals from the aortic component of the second heart sound to the peak of the early diastolic wave (IIA-Ews) along both the transverse (N: 142+/-18 ms, HT: 154+/-19 ms) and longitudinal (N: 151 16 ms, HT: 162+/-20 ms) axes were longer in the patient group. In 29 patients, Ews along both axes correlated negatively (transverse: r = -0.80, P < .0001; longitudinal: r = -0.71, P < .0001) and IIA-Ews correlated positively (transverse: r = 0.81, P < .0001; longitudinal: r = 0.74, P < .001) with the time constant of the LV pressure decay during isovolumic diastole. The Aws along both axes in the 24 patients without pseudonormalization in transmitral flow velocity correlated positively (transverse: r = 0.60, P < .001; longitudinal: r = 0.74, P < .0001) with the LV end-diastolic pressure. In conclusion, LV relaxation and filling along the longitudinal and transverse axes were impaired in many patients with hypertension. Pulsed TDI was useful for evaluating LV diastolic dynamics in this disease.

Echocardiographic characteristics and causal mechanism of physiologic mitral regurgitation in young normal subjects.

BACKGROUND: It has become evident that mitral regurgitation (MR) is not uncommon in healthy subjects, and Doppler color flow mapping is a technique that imparts important information relevant to its detection. HYPOTHESIS: Using transthoracic echocardiography, this study evaluated the mechanism of physiologic MR in young normal subjects using transthoracic echocardiography. METHODS: The study population consisted of 48 young normal subjects (mean 21 +/- 5 years) with MR (physiologic MR group), 40 age-matched young normal subjects (mean 20 +/- 5 years) without MR (control group), 45 patients (mean 41 +/- 15 years) with mitral valve prolapse with MR (MVP group), and 27 patients (mean 59 +/- 13 years) with ruptured chordae tendineae (rupture group). RESULTS: Men were predominant in the rupture group, whereas there were no significant gender differences in the other three groups. Left ventricular end-diastolic dimension and left atrial systolic dimension were slightly smaller in the physiologic MR group than in the control group, but were significantly smaller than those in the MVP and rupture groups. The ratio of the maximum anteroposterior diameter to the maximum transverse diameter on chest radiography and the ratio of the short- to long-axis diameter of the left ventricular cavity at end diastole, determined from two-dimensional short-axis echocardiogram, were significantly lower in the physiologic MR group than in the other three groups. Mitral regurgitation occurred more frequently at the posteromedial commissural site in the physiologic MR and MVP groups, whereas there was no preference for location in the rupture group. Early systolic MR was often observed in the physiologic MR group, whereas pansystolic MR was common in the MVP and rupture groups. CONCLUSION: As a causal mechanism for physiologic MR detected in young normal subjects, "flattening" of the thorax during growth may cause morphologic abnormalities of the left atrial and ventricular cavities, resulting in spatial imbalance of the mitral complex and resulting in malcoaptation of the valve.

Transesophageal echocardiographic prediction of initially successful electrical cardioversion of isolated atrial fibrillation. Effects of left atrial appendage function.

Left atrial appendage (LAA) flow velocities prior to electrical cardioversion were recorded using transesophageal pulsed Doppler echocardiography to predict initially successful cardioversion of isolated atrial fibrillation (AF). Patients with AF were placed into either a success group (19 patients) in which sinus rhythm was maintained for at least 2 days or a failure group (12 patients). The duration of AF was shorter in the success group. The maximum left atrial diameter was the same for the two groups. The maximum LAA area was smaller in the success group. The maximum forward and backward LAA velocities were greater in the success group, as were the mean forward and backward LAA velocities. In the patients with mean LAA flow velocities greater than 19 cm/sec, the success of cardioversion could be predicted with high sensitivity (80%) and specificity (88%). We conclude that the duration of AF, the maximum LAA area, and LAA flow velocities prior to cardioversion predict the initial recovery of sinus rhythm for isolated AF.

Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular relaxation.

Conventional assessment of left ventricular (LV) relaxation by calculating the time constant of LV pressure decay during the isovolumic diastole requires an invasive approach. Conversely, noninvasive parameters obtained by measuring isovolumic relaxation time and transmitral flow velocity often give inaccurate information. Using LV pressure curve, pulsed Doppler echocardiography, and pulsed Doppler tissue imaging in 38 patients with heart disease and 12 control subjects, we calculated the time constant and recorded transmitral flow velocity and motion velocities at the endocardial portions of the ventricular septum and LV posterior wall. Compared with the controls, patients exhibited a prolonged time constant, a decreased peak early diastolic velocity of the LV posterior wall, and a prolonged time interval from the second heart sound to the peak of the early diastolic wave. The time constant correlated well with the isovolumic relaxation time and various parameters calculated from the transmitral flow velocity, except in patients with elevated LV end-diastolic pressure. In all subjects, the time constant correlated negatively with the peak early diastolic velocity of the posterior wall and positively with the time from the second heart sound to the peak of the early diastolic wave. Thus, early diastolic parameters derived from the motion velocity of the LV posterior wall by pulsed Doppler tissue imaging were closely related to the time constant. This technique may allow noninvasive evaluation of abnormal LV relaxation in patients with various heart diseases.