Left ventricular to left arial volume ratio in the assessment of filling pressure in patients with dyspnoea and preserved ejection fraction.

Introduction: Assessing filling pressure (FP) remains a clinical challenge despite advancements in non-invasive imaging techniques. This study investigates the utility of echocardiographic left ventricular (LV) to left atrial (LA) volume ratio in estimating the resting FP in patients with dyspnoea and preserved ejection fraction (EF). Methods: This study is a prospective, single-centre analysis of 53 consecutive patients with dyspnoea (New York Heart Association grade 2 or 3) and LVEF of ≥50% (mean age 71 ± 10 years) who underwent cardiac catheterisation, including direct measurement of LA pressure at rest using retrograde technique. Echocardiographic data were obtained 1.5 ± 1.0 h after cardiac catheterisation. The patients were divided into two groups: Group 1 consisted of individuals with elevated FP, indicated by a mean LA pressure or mean pulmonary capillary wedge pressure of >12 mmHg, and Group 2 comprised of patients with normal FP. The LV and LA volumes were measured at three specific points: the minimum volume (LVES, LAmin), the volume during diastasis (LVdias, LAdias), and the maximum volume (LVED, LAmax). The corresponding LV/LA volume ratios were analysed: end-systole (LVES/LAmax), diastasis (LVdias/LAdias), and end-diastole (LVED/LAmin). Results: The patients in Group 1 exhibited lower LV/LA volume ratios compared with those in Group 2 (LVES/LAmax 0.44 ± 0.12 vs. 0.60 ± 0.23, P = 0.0032; LVdias/LAdias 1.13 ± 0.30 vs. 1.56 ± 0.49, P = 0.0007; LVED/LAmin 2.71 ± 1.57 vs. 4.44 ± 1.70, P = 0.0004). The LV/LA volume ratios correlated inversely with an increased FP (LVES/LAmax, r = -0.40, P = 0.0033; LVdias/LAdias, r = -0.45, P = 0.0007; LVED/LAmin, r = -0.55, P < 0.0001). Among all the measurements, the LVdias/LAdias ratio demonstrated the highest discriminatory power to distinguish patients with elevated FP from normal FP, with a cut-off value of ≤1.24 [area under the curve (AUC) = 0.822] for the entire group, encompassing both sinus rhythm and atrial fibrillation. For patients in sinus rhythm specifically, the cut-off value was ≤1.28 (AUC = 0.799), with P < 0.0001 for both. The LVdias/LAdias index demonstrated non-inferiority to the E/e' ratio [ΔAUC = 0.159, confidence interval (CI) = -0.020-0.338; P = 0.0809], while surpassing the indices of LA reservoir function (ΔAUC = 0.249, CI = 0.044-0.454; P = 0.0176), LA reservoir strain (ΔAUC = 0.333, CI = 0.149-0.517; P = 0.0004), and LAmax index (ΔAUC = 0.224, CI = 0.043-0.406; P = 0.0152) in diagnosing patients with elevated FP. Conclusion: The study presents a straightforward and reproducible method for non-invasive estimation of FP using routine TTE in patients with dyspnoea and preserved EF. The LVdias/LAdias index emerges as a promising indicator for identifying elevated FP, demonstrating comparable or even superior performance to established parameters.

Left heart remodelling in hypertensive patients: a comprehensive echocardiography and computed tomography study.

Objectives: This study aimed to assess left heart remodelling changes in hypertension, excluding underlying ischaemic heart disease, utilising computed tomography coronary angiography (CTCA) and transthoracic echocardiography (TTE). Methods: A total of 178 patients (mean age 60 ± 9 years, 53% female) were enrolled in the study: Group 1 consisted of patients with essential hypertension (n = 96, Group 1), and Group 2 served as age-matched controls (n = 82, Group 2). All participants underwent both CTCA and TTE. TTE measurements included left ventricle (LV) concentricity and function and left atrial (LA) volume and function. Using both CTCA and TTE, we measured LV diastasis volume (LVdias) and LA diastasis volume (LAdias). Results: LV mass index and LV mass/height2.7 were similar in both the groups. However, Group 1 had a higher prevalence of concentric LV remodelling, characterised by a larger mean LV wall thickness, increased relative wall thickness ratio, and a reduced ratio of LV end-diastolic volume (LVED) index to mean wall thickness (55 ± 14 vs. 65 ± 15, p = 0.0007). Group 1 showed higher LAdias and LA minimal volumes, while LA reservoir function was lower in Group 2. The LVdias/LAdias ratio was lower in Group 1 compared to Group 2 (TTE 1.77 ± 0.61 vs. 2.24 ± 1.24, p = 0.0025, CTCA 1.50 ± 0.23 vs. 1.69 ± 0.41, p = 0.0002). A composite score based on four combined TTE parameters, namely, LVED index/mean wall thickness ≤57, ratio of early diastolic mitral inflow to mitral annular tissue velocities (E/e') >8, LVdias/LAdias ≤1.62, and LA reservoir function ≤0.58, yielded the highest discriminatory power (area under the curve-AUC = 0.772) for distinguishing patients with hypertensive heart disease (HHD). Collectively, we refer to these parameters as the LEDA score, with each parameter scored as one point. For LEDA scores of 0, 1, 2, 3, 4, the probability of underlying HHD was 0%, 23%, 59%, 80%, and 95%, respectively. Furthermore, a CTCA-derived LVdias/LAdias ≤1.76, considered as a single parameter, demonstrated modest accuracy in differentiating patients with HHD (AUC = 0.646). Conclusions: The TTE LEDA score, based on four parameters, namely, LVED index/mean wall thickness, E/e', LVdias/LAdias, and LA reservoir function, proved to be the most effective in defining left heart remodelling in hypertension.

Incremental role of CT coronary angiography in the assessment of left ventricular diastolic function.

OBJECTIVE: To determine whether Computed Tomography (CT) coronary angiography (CTCA) has clinical value for the assessment of left ventricular (LV) diastolic dysfunction (DD) beyond traditional information on coronary artery anatomy. METHOD: In this retrospective study, a consecutive group of 72 patients (mean age 59±13 years)-who met the eligibility criteria of sinus rhythm, no significant valvular abnormalities, and who had transthoracic echocardiogram (TTE)-were analysed. The CTCA was prospectively triggered during diastole. Outcomes of interest were CTCA derived LV and left atrial (LA) volumes, diastolic expansion (DE) index: LV volume÷LA volume and DE fraction (DEF): [(LV volume-LA volume)÷LV volume]×100. TTE-LA volume was measured as maximum, minimum and pre-A. Studied patients were divided according to the current classification of LVDD as a reference standard. A small subgroup of nine patients underwent further invasive cardiac catheterisation. RESULTS: CTCA-LV and LA volumes were larger compared with TTE, 37%±20% and 11%±21%, respectively. CTCA-LA volume correlated well with all TTE-LA volumes (maximum: R2=0.58; pre-A wave: R2=0.39; minimum: R2=0.26; p<0.0001) with the smallest differences in maximum LA volume (9±32 mL; mean±2 SD). The DE and DEF correlated with both LA function and LVDD. DE >1.65 and DE <1.40 have good specificity (85% and 88%, respectively), and positive predictive value to differentiate LVDD. DE and DEF were dependent on the patients' age but independent of other variables. CONCLUSIONS: CTCA derived diastasis volume indices can provide additional quantifiable information on LVDD.

The role of left and right ventricular early diastolic Doppler tissue echocardiographic indices in the evaluation of acute rejection in orthotopic heart transplant.

BACKGROUND: The aim was to evaluate whether Doppler tissue echocardiographic early diastolic indices of both the right and left ventricle (LV) may assist in the detection of acute heart transplant (HT) rejection. METHODS: In all, 44 consecutive patients with HT (mean age 52.0 +/- 9.6 years, 39 men) were divided into group 1 with no rejection (histopathology grade < or = 2) and group 2 with acute (severe) rejection (grade > or = 3A). In group 2, echocardiographic examinations were performed before (A), during (B), and after (C) acute rejection. RESULTS: Although patients with HT in group 2B compared with group 1 had lower early diastolic velocities at medial/septal (E Med ) and tricuspid/lateral (E Tric ) annulus, as a result of substantial data overlapping this finding did not allow for the detection of patients with acute rejection. In group 2B, both onsets of E Med and E Tric were delayed and LV early diastolic mitral/lateral annulus velocities (E Mitr ) markedly preceded E Tric (E Tric -E Mitr 68 +/- 45 milliseconds for group 2B vs 7 +/- 43 milliseconds for group 1 and 14 +/- 40 milliseconds for group 2A; P < .01). Additionally, patients with HT in group 2B had pathologically positive late isovolumic relaxation myocardial velocity gradient of LV posterior wall compared with group 1 or group 2A (1.5 +/- 1.4 s -1 vs -0.3 +/- 2.0 s -1 or 0.3 +/- 1.8, respectively; P < .01). Late isovolumic relaxation myocardial velocity gradient greater than 0.1 s -1 and timing differences between onsets of: (1) mitral early diastolic velocity (E wave) and E Med greater than -35 milliseconds; and (2) E Tric -E Mitr greater than 15 milliseconds allowed for the distinction of patients with acute HT rejection (group 2B vs 1) with sensitivity and specificity greater than 0.80. CONCLUSIONS: For patients with HT and acute rejection abnormal Doppler tissue echocardiographic indices may be caused by both: (1) altered early diastolic untwist of the oblique LV fibers; and (2) the delay in early diastolic right ventricular relaxation. Late isovolumic relaxation myocardial velocity gradient and early diastolic timing intervals (mitral E wave-E Med and E Tric -E Mitr ) are promising new echocardiographic markers that can be used in the surveillance for acute rejection in patients with HT.

Biventricular diastolic behaviour in patients with hypertrophic and hereditary hemochromatosis cardiomyopathies.

AIM: To define biventricular diastolic behaviour in patients with cardiomyopathies with predominant diastolic left ventricular (LV) dysfunction. METHODS AND RESULTS: Doppler tissue echocardiography and both mitral and tricuspid Doppler inflow profiles were investigated in hypertrophic (n = 17), hereditary hemochromatosis (n = 12) cardiomyopathies and age-matched normals (n = 31). The cardiomyopathy group had both lower early diastolic mitral lateral annular (El), cm/s (13.9 +/- 6.5) and medial (Em) (10.0 +/- 4.5) velocities compared with normals (19.5 +/- 5.5, 15.9 +/- 3.4, p < 0.01, respectively). In the cardiomyopathy group, late isovolumic relaxation myocardial velocity gradient (IVR-MVG) (s(-1)) was positive compared with negative in normals (1.3 +/- 1.3 vs. -0.7 +/- 1.4, p < 0.01, respectively). In both the cardiomyopathy group and in normals the onset of the tricuspid E-wave preceded the onset of the mitral E-wave. However, the onset of early diastolic tricuspid annular (Et) motion preceded the onset of El (ms) only in normals, but not in the cardiomyopathies (43 +/- 26 vs. -8 +/- 44, p < 0.01, respectively). In the cardiomyopathy group there was a positive correlation between the onset of Et and abnormally positive late IVR-MVG (r = 0.51, p = 0.002). CONCLUSIONS: Biventricular early diastolic behaviour is abnormal in the selected group of cardiomyopathy patients. The delay in the Et (early diastolic longitudinal right ventricular relaxation) may have a negative effect on LV diastolic function.

A fatal case of idiopathic restrictive cardiomyopathy.

We describe the clinical features of idiopathic restrictive cardiomyopathy in a female infant. A marked elevation of left ventricular end-diastolic pressure, and profoundly abnormal myocardial relaxation, were detected with the use of Doppler blood flow echocardiography, coupled with the relatively new technique of Doppler tissue echocardiography. There was no clinical evidence of ongoing heart failure, but she had signs of myocardial ischaemia, and unfortunately died suddenly at the age of 13 months.

Eosinophilic heart: marked left ventricular wall thickening and myocardial dysfunction improving with corticosteroid therapy.

We report a case of a 34-year-old male with acute severe heart failure associated with marked concentric left ventricular wall thickening and biopsy evidence of eosinophilic myocardial infiltrate. This appears to be an unusual description of this degree of concentric myocardial thickening in eosinophilic myocarditis coupled with Doppler tissue echocardiography. Following high-dose corticosteroid treatment, wall thickness, systolic and diastolic left ventricular function normalized and the patient experienced a dramatic clinical improvement.

Doppler tissue echocardiographic features of cardiac amyloidosis.

The purpose of the study was to assess whether quantification of myocardial involvement by Doppler tissue echocardiography (DTE) enhances the accuracy of echocardiographic characterization of cardiac amyloidosis (CA). A group of 36 patients with CA (mean age 58 +/- 13 years; 22 male) and 40 age-matched control patients were studied. Patients with CA were divided into CA-1 subgroup with nonrestrictive (n = 22) and CA-2 with restrictive left ventricular (LV) filling pattern (n = 14). Peak lateral and medial mitral annulus velocities by pulsed wave DTE were measured in systole, early diastole, and late diastole. Using color M-mode DTE of the LV posterior wall, mean myocardial velocities (MMV) and myocardial velocity gradient (MVG) were measured during ventricular ejection, early and late isovolumic relaxation (IVR), rapid ventricular filling, and atrial contraction. In both CA-1 and CA-2 groups, mitral annulus velocities, MMV, and all MVG were lower than those measured in control patients, with the exception of peak late diastolic annulus velocities at lateral side and MMV in atrial contraction. MVGs in both early IVR and rapid ventricular filling were lower in the CA-1 as compared with the CA-2 group. Late IVR-MVG was negative in control patients and positive in patients with CA indicating a faster movement of the subendocardium rather than the subepicardium during late IVR in patients with CA (0.88 +/- 0.50 s(-1) vs -0.40 +/- 1.59 s(-1); P <.001). The following parameters: peak early diastolic annulus velocities at lateral side < or = -12 cm/s, peak early diastolic annulus velocities at medial side < or = -10 cm/s, early IVR-MMV < or = -2.5 cm/s, early IVR-MVG < or = -0.7 s(-1), and late IVR-MVG > or = 0.5 s(-1) differentiated patients with CA from control patients with an overall accuracy of 0.82, 0.83, 0.81, 0.87, and 0.81, respectively. In patients with CA, reduction in early IVR-MMV was independent of patients' age and LV mass. DTE indices proved helpful in differentiating patients with CA from control patients including those patients with CA who had borderline conventional echocardiographic features and nonrestrictive LV filling pattern.

The role of Doppler left ventricular filling indexes and Doppler tissue echocardiography in the assessment of cardiac involvement in hereditary hemochromatosis.

Although cardiac dysfunction in hereditary hemochromatosis (HHC) can be evaluated by conventional echocardiography, findings are often not specific. To test the hypothesis that the assessment of (1) conventional Doppler left ventricular filling indexes and (2) intrinsic elastic properties of the myocardium by Doppler tissue echocardiography can both enhance the accuracy of echocardiographic diagnosis of cardiac involvement in HHC, a group of 18 patients with HHC (mean age 50 +/- 17 years) and 22 age-matched healthy subjects were studied. The following indexes were characteristic for HHC: (1) the duration of atrial reversal measured from pulmonary venous flow (ms) was longer (118 +/- 20 vs 90 +/- 16; P <.001); (2) systolic lateral mitral, early-diastolic medial mitral, and early-diastolic lateral tricuspid annular velocities were reduced by 23%, 31%, and 13%, respectively; (3) late-diastolic mean myocardial velocity and myocardial velocity gradient (MVG) were also reduced by 22% and 34%, respectively. Late-isovolumic relaxation (late-IVR) MVG (s(-1)) was positive in HHC as opposed to negative in healthy subjects (1.72 +/- 0.85 vs -0.89 +/- 1.15; P <.001) indicating impaired early-diastolic subepicardial relaxation in HHC. The assessment of atrial reversal flow duration, the difference in duration between A-wave and atrial reversal flow, and the presence of positive late IVR-MVG findings were the most accurate variables to differentiate patients with HHC from healthy subjects (80%, 67%, 94% sensitivity and 90%, 95%, 86% specificity, respectively).

Quantification of mitral regurgitation orifice area by 3-dimensional echocardiography: comparison with effective regurgitant orifice area by PISA method and proximal regurgitant jet diameter.

BACKGROUND: The evaluation of mitral regurgitation (MR) by 3-dimensional (3D) echo has generally been performed by reconstruction of Doppler regurgitant jets but there are little data on measuring anatomic regurgitant orifice area (AROA) directly from 3D mitral valve (MV) reconstructions. METHODS AND RESULTS: Transoesophageal echo (TOE) 3D images were acquired from 38 unselected patients (age 59+/-11 years, ten in atrial fibrillation) with various degrees of MR. In all patients MV was reconstructed en face from the left atrium (LA) and the left ventricle (LV). AROA was measured by planimetry from 3D pictures and compared to the effective regurgitant orifice area (EROA) by proximal isovelocity surface area and proximal MR jet width from 2D echo. AROA was measured in 95% of patients from LA, 89% from LV and in 84% from both LA and LV. Good correlation was found between EROA and AROA measured from both LA (r=0.97, P<0.0001) and LV (r=0.87, P<0.0001). The mean difference between LA-AROA and EROA was -3.01+/-6.12 mm(2) and -7.18+/-13.84 mm(2) for LV-AROA (P<0.01, respectively). An acceptable correlation was found between the proximal MR jet width and AROA from LA (r=0.71, P<0.0001) and LV perspective (r=0.68, P<0.0001). AROA>or=25 mm(2) differentiated mild MR (graded 1-2) from moderately severe (graded 3-4) with 80-90% accuracy. CONCLUSIONS: 3D TOE provides important quantitative information on both the mechanism and the severity of MR in an unselected group of patients. AROA enables quantification of MR with excellent agreement with the accepted clinical method of proximal flow convergence.

Primary aortic valve replacement with cryopreserved aortic allograft: an echocardiographic follow-up study of 570 patients.

BACKGROUND: Despite the many advantages of an aortic allograft valve (AAV) over a prosthetic aortic valve, its durability is suboptimal. The aims of the present study were to document characteristic features of AAV dysfunction and to investigate factors influencing the development of such dysfunction. METHODS AND RESULTS: A group of 570 patients (mean age, 48+/-16 years) with a cryopreserved AAV underwent a follow-up echocardiographic study (mean time after surgery, 6.8 years; range, 1.0 to 22.9 years). Significant AAV regurgitation was present in 14.7% of patients, and AAV stenosis was present in 3.2%. The root replacement subgroup had the smallest number of patients with significant AAV regurgitation (5.0%) compared with the subcoronary (23.0%) or the inclusion cylinder technique subgroup (14.7%). After 10 to 15 years after AAV replacement, grade > or =2 AAV dysfunction was present in 40% of patients in the subcoronary subgroup, but no significant dysfunction was observed in patients in the root replacement subgroup (P<0.001). Smaller host aortic annulus size in both subcoronary (coefficient, -0.145; P=0.013) and root replacement subgroups (coefficient, -0.249; P=0.011) was associated with more frequent AAV dysfunction (grade > or =2). In addition, significant AAV dysfunction was more frequent when patients were younger (coefficient, -0.020; P=0.015) in the subcoronary subgroup and the donor was older (coefficient, 0.054; P=0.019) in the root replacement subgroup. CONCLUSIONS: The present study indicates that the root replacement technique is associated with less frequent AAV degeneration. Our findings should help in establishing more strict selection criteria for surgical replacement procedure type and patient/donor factors for AAV replacement and, therefore, could lead to improve AAV longevity.