Agreement between anatomical M-mode and tissue Doppler imaging in the assessment of fetal atrioventricular annular plane displacement in uncomplicated pregnancies: A prospective longitudinal study.

AIM: To evaluate the level of agreement between M-mode and pulsed-wave tissue Doppler imaging (PW-TDI) techniques in assessing fetal mitral annular plane systolic excursion (MAPSE), tricuspid annular plane systolic excursion (TAPSE) and septal annular plane systolic excursion (SAPSE) in a low-risk population. METHODS: This prospective longitudinal study included healthy fetuses assessed from 18 to 40 weeks of gestation. Tricuspid annular plane systolic excursion, MAPSE and SAPSE were measured using anatomical M-mode and PW-TDI. The agreement between the two diagnostic tests was assessed using Bland-Altman analysis. RESULTS: Fifty fetuses were included in the final analysis. Mean values of TASPE were higher than that of MAPSE. There was a progressive increase of TAPSE, MAPSE and SAPSE values with advancing gestation. For each parameter assessed, there was an overall good agreement between the measurements obtained with M-mode and PW-TDI techniques. However, the measurements made with M-mode were slightly higher than those obtained with PW-TDI (mean differences: 0.03, 0.05 and 0.03 cm for TAPSE, MAPSE and SAPSE, respectively). When stratifying the analyses by gestational age, the mean values of TAPSE, MAPSE and SAPSE measured with M-Mode were higher compared to those obtained with PW-TDI, although the mean differences between the two techniques tended to narrow with increasing gestation. Tricuspid annular plane systolic excursion, MAPSE and SAPSE measurements were all significantly, positively associated with gestational age (all P < 0.001). CONCLUSION: Fetal atrioventricular annular plane displacement can be assessed with M-mode technique, or with PW-TDI as the velocity-time integral of the myocardial systolic waveform. Atrioventricular annular plane displacement values obtained with M-mode technique are slightly higher than those obtained with PW-TDI.

Evaluation of the Clinical Utility of Transesophageal Echocardiography and Invasive Monitoring to Assess Right Ventricular Function During and After Pulmonary Endarterectomy.

OBJECTIVE: Patients undergoing pulmonary endarterectomy (PEA) have impaired right ventricular function. The authors sought to assess the clinical utility of commonly used perioperative echocardiographic and right heart catheter measurements in patients undergoing PEA. DESIGN: A single-center prospective observational study. SETTING: The study was conducted in a quaternary care cardiac surgical center in the United Kingdom. PARTICIPANTS: Patients undergoing PEA between April 2015 and January 2016. INTERVENTIONS: Thermodilution cardiac index and echocardiography variables were measured at 3 time points: before sternotomy (T1), after pericardial incision (T2), and after sternal closure (T3). Six-month follow-up echocardiography and 6-minute walk (6-MWT) test were performed. MEASUREMENTS AND MAIN RESULTS: Fifty patients were recruited and complete data sets were available for 41 patients. Tricuspid annular plane systolic excursion declined after pericardial incision and cardiopulmonary bypass (T1: 15 ± 4 mm, T2: 13 ± 4 mm, T3: 7 ± 2 mm; p < 0.0001), returning to baseline 6 months postoperatively. Cardiac index (T1: 2.5 ± 0.7 L/min/m2, T2: 2.6 ± 0.6 L/min/m2, T3: 2.3 ± 0.5 L/min/m2; p = 0.07) and right ventricular fractional area change (T1: 36 ± 11%, T2: 40 ± 12%, T3: 40 ± 9%; p = 0.12) were preserved perioperatively. 6-MWT improved from baseline (294 ± 111 m) to follow-up (357 ± 107 m) (p < 0.001). Pulmonary vascular resistance at T3 correlated moderately with follow-up 6-MWT (R = -0.60). CONCLUSIONS: In patients undergoing PEA, invasive measurements and echocardiography assessment of right ventricular function are not interchangeable. Tricuspid annular plane systolic excursion is not a reliable measure of right ventricular function perioperatively. Pulmonary vascular resistance shows moderate correlation with postoperative functional capacity.

Prevalence of left ventricular diastolic dysfunction in European populations based on cross-validated diagnostic thresholds.

BACKGROUND: Different diagnostic criteria limit comparisons between populations in the prevalence of diastolic left ventricular (LV) dysfunction. We aimed to compare across populations age-specific echocardiographic criteria for diastolic LV dysfunction as well as their correlates and prevalence. METHODS: We measured the E and A peaks of transmitral blood flow by pulsed wave Doppler and the e' and a' peaks of mitral annular velocities by tissue Doppler imaging (TDI) in 2 cohorts randomly recruited in Belgium (n = 782; 51.4% women; mean age, 51.1 years) and in Italy, Poland and Russia (n = 476; 55.7%; 44.5 years). RESULTS: In stepwise regression, the multivariable-adjusted correlates of the transmitral and TDI diastolic indexes were similar in the 2 cohorts and included sex, age, body mass index, blood pressure and heart rate. Similarly, cut-off limits for the E/A ratio (2.5th percentile) and E/e' ratio (97.5th percentile) in 338 and 185 reference subjects free from cardiovascular risk factors respectively selected from both cohorts were consistent within 0.02 and 0.26 units (median across 5 age groups). The rounded 2.5th percentile of the E/A ratio decreased by ~0.10 per age decade in these apparently healthy subjects. The reference subsample provided age-specific cut-off limits for normal E/A and E/e' ratios. In the 2 cohorts combined, diastolic dysfunction groups 1 (impaired relaxation), 2 (possible elevated LV filling pressure) and 3 (elevated E/e' and abnormally low E/A) encompassed 114 (9.1%), 135 (10.7%), and 40 (3.2%) subjects, respectively. CONCLUSIONS: The age-specific criteria for diastolic LV dysfunction were highly consistent across the study populations with an age-standardized prevalence of 22.4% vs. 25.1%.

Subtle systolic dysfunction may be associated with the tendency to develop diastolic heart failure in patients with preserved left ventricular ejection fraction.

BACKGROUND: We looked for an answer to the question of whether diastolic heart failure (DHF) is a reality or all heart failures are systolic. METHOD: 300 cases (hypertensive, aged, obese, etc.), not being diagnosed DHF, with preserved left ventricular (LV) ejection fraction (EF) but having the tendency to develop DHF in future were examined. One hundred and eighty cases without exclusion criteria were selected. Cases were assigned to three groups according to noninvasively obtained pulmonary capillary wedge pressure (PCWP). RESULTS: In cases with higher PCWP (>10 mmHg), transmitral A velocity was increased (P < 0.001) and among the pulsed wave tissue Doppler imaging (pw-TDI) parameters Ea velocity was decreased (P < 0.001) and Ea-dt was prolonged (P < 0.005). In cases with lower PCWP (<8 mmHg), transmitral E velocity was higher (P< 0.001). Furthermore, a more meaningful relationship was found between PCWP and systolic pw-TDI parameters. In all the groups, it was observed that Sa velocity was progressively decreased and Q-Sa interval was progressively prolonged as PCWP increased (for all the groups P < 0.046). CONCLUSION: The question whether DHF is a reality or all heart failures are systolic may be answered as follows. Subtle systolic dysfunction may be associated with the tendency to develop DHF in patients with preserved LV ejection fraction. As in systolic heart failure (EF < 45%), in patients with preserved systolic function (EF > or = 45%), systolic and diastolic functions may impair together. The pw-TDI method may be more sensitive than standard echocardiography parameters in detection of systolic dysfunction in cases with preserved EF.

Myocardial systolic activation delay in patients with left bundle branch block and either normal or impaired left ventricular function.

AIM OF THE STUDY: to evaluate determinants of myocardial activation delay of both left (LV) and right (RV) ventricle in patients with left bundle branch block (LBBB) and either normal or impaired LV ejection fraction (EF). METHODS: From an initial cohort of patients with LBBB, 42 patients with dilated cardiomyopathy (group A) and 33 with normal global LV systolic function (group B), all comparable in age and sex, underwent standard Doppler echo, pulsed Doppler myocardial imaging (DMI), and coronary angiography. Using DMI, the following regional parameters were evaluated in five different basal myocardial segments (LV anterior, inferior, septal, lateral walls-RV lateral wall): systolic (Sm), early- and late-diastolic (Em and Am) peak velocities. As index of myocardial systolic activation was calculated: precontraction time (PCTm) (from the beginning of Q-wave of ECG to the onset of Sm). Intraventricular systolic dyssynchrony was analyzed by difference of PCTm in different LV myocardial segments. Interventricular activation delay was calculated by the difference of PCTm between the most delayed LV segment and RV lateral wall. RESULTS: Patients of group A showed increased heart rate (HR), QRS duration and LV end-diastolic diameter, and reduced LV EF. By DMI, patients of group A showed reduced myocardial peak velocities and a significant intraventricular delay in activation of LV lateral wall, with increased regional PCTm (P < 0.001). In addition, patients with dilated cardiomyopathy showed a more pronounced interventricular dyssynchrony, even after adjustment for HR and QRS duration. By receiver operating characteristic (ROC) curve analysis, a cut-off value of 55 msec of interventricular delay showed 86% sensitivity and 92% specificity in identifying patients with impaired EF. In the overall population, by use of stepwise forward multivariate linear regression analyses, LV end-diastolic diameter (beta coefficient = 0.52; P < 0.001) and LV EF (beta coefficient =-0.58; P < 0.0001) were the only independent determinants of interventricular activation delay. CONCLUSIONS: Pulsed DMI is an effective noninvasive technique for assessing the severity of regional delay in activation of LV walls in patients with LBBB. The impairment of interventricular systolic sychronicity is strongly related to LV dilatation and to the degree of global systolic dysfunction. Therefore, patients with dilated cardiomyopathy suitable for cardiac resynchronization therapy may be better selected.

Strategy for optimal aortic regurgitation quantification by Doppler echocardiography: agreement among different methods.

BACKGROUND: Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined. METHODS: Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested. RESULTS: Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P <.01), in apical jet area when mitral valve disease was present (84% vs 65%, P <.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P <.002 and 77% vs 53%, P <.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%). CONCLUSIONS: Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

[Interobserver reproducibility of Doppler ultrasound measurements of the fetal ductus arteriosus]. / Interobserver-Reproduzierbarkeit von dopplersonographischen Messungen im fetalen Ductus arteriosus.

In a subgroup of 418 Doppler flow velocimetries of the fetal ductus arteriosus, which were performed to evaluate possible effects of low dose aspirin on fetal hemodynamics, an interobserver reproducibility study was carried out. 55 pulsed Doppler measurements of the fetal ductus arteriosus were performed within 24 hours by two different examinators. Pulsatility Index (PI), peak velocity (Vmax), mean velocity (Vmean) and enddiastolic velocity (Vmin) were obtained from the flow velocity profiles and correlation and variability coefficients were calculated. Peak velocity has been shown to be the most reproducible parameter with highest correlation and lowest variability.

Use of the continuity equation for transesophageal Doppler assessment of severity of proximal left coronary artery stenosis: a quantitative coronary angiography validation study.

OBJECTIVES: We tested the value of transesophageal Doppler echocardiography (TEDE) for quantitating proximal left coronary artery (LCA) stenosis by using the continuity equation. BACKGROUND: The continuity equation applied to a stenosis states that the ratio of the time-velocity integral (TVI) of prestenotic to stenotic flow velocities is equal to the ratio of stenotic to prestenotic cross-sectional areas. TEDE allows the measurement of coronary blood flow velocities within the proximal part of the LCA. METHODS; Forty-one patients with a stenosis of the proximal or mid left anterior descending coronary artery or with a nonostial stenosis of the left main coronary artery were studied. Coronary flow velocities were recorded by TEDE guided by color flow imaging. Prestenotic velocities were recorded by pulsed Doppler echocardiography and transstenotic velocities were recorded by pulsed or high pulse repetition frequency or continuous wave Doppler echocardiography. The prestenotic and transstenotic diastolic TVIs were calculated and the TEDE-derived percent area stenosis was calculated as (1 - TVI ratio) x 100. Quantitative angiography lesion analysis was performed using a computer-assisted automated edge-detection system. RESULTS: TEDE recordings were successful in 35 of the 41 patients. A good linear correlation was found between TEDE and quantitative angiographically derived percent area stenosis (r = 0.89, p = 0.0001, SEE 5.7). However, TEDE measurements underestimated the actual percent area stenosis (slope of regression 0.54). A better agreement (slope 1.08) was obtained after dividing prestenotic velocity by 2 in the continuity equation, based on the assumption of a parabolic cross-sectional velocity profile in the prestenotic segment. CONCLUSIONS: TEDE may be used for quantitating stenosis of the proximal part of the LCA with the use of a modified continuity equation that takes into account the parabolic velocity profile in the normal prestenotic segment.

[Left ventricular diastolic function in patients with type-I diabetes mellitus (based on pulsed Doppler echocardiographic data)]. / Diastolicheskaia funktsiia levogo zheludochka u bol'nykh sakharnym diabetom I tipa (po dannym impul'snoi dopplerékhokardiografii).

Diastolic function was studied of left ventricle by pulse Doppler echocardiography in 42 patients with type I diabetes mellitus (DM) and 46 essentially healthy individuals. In DM patients diastolic function was manifested by rise in peak velocity of atrial filling, decrease in ratio of peak velocity of early filling to that of late one, increase in left ventricular end-diastolic pressure. The findings available suggest the atrial phase has an important part in the structure of diastole in DM patients because of a combined influence of tachycardia and increased rigidity of left ventricular myocardium. Values for early filling in the patients did not differ from those in controls. A conclusion is drawn to the effect that in DM patients tachycardia and hypercatecholaminemia may partly mask disturbances in relaxation.

[An echocardiographic study of the aortic root in ankylosing spondylitis]. / Estudio ecocardiográfico de la raíz aórtica en la espondilitis anquilosante.

The inflammatory condition in ankylosing spondylitis (AS) may affect cardiac structures, being the aortic valve mostly studied. Several studies regard the existence of a subaortic ridging as specific for AS. Our objective was to assess abnormalities in the aortic root in AS using echocardiography and its relation to HLA B-27 and clinical parameters of the disease. Thirty patients with no clinical, radiographic or electrocardiographic evidence of cardiovascular disease were studied by monodimensional, bidimensional and Doppler echocardiography. After an initial ultrasound examination to detect subclinical cardiac abnormalities, aortic root dimensions were measured at the aortic annulus, at the tip of the cusps and 1 cm above the cusps. The existence of subaortic ridging was assessed using bidimensional echocardiography. As clinical parameters were estimated duration of AS, sacroiliac joint X-ray involvement and activity of disease. The results are compared with those in a control group of thirty healthy people with same age, sex and corporal surface. No statistical differences were observed in the mean values of aortic root dimensions between the two groups; in patients with AS were not seen significant differences in the echocardiographic measurements related to clinical parameters or HLA B-27. Only in one patient was observed the characteristic subaortic ridging (4%, NS compared to control group). We conclude, in contrast to other authors, that in patients with AS without cardiovascular disease echocardiographic examination of aortic root does not detect significant abnormalities.

Measurement of aortic blood flow by Doppler echocardiography: temporal, technician, and reader variability in normal subjects and the application of generalizability theory in clinical research.

Although Doppler echocardiographic measurements of aortic flow have been found to correlate with stroke volume, the reliability of this technique is unknown. The purpose of this study was to measure the reliability of Doppler estimates of cardiac output by identifying and estimating the magnitude of different sources of error. We measured the reliability of Doppler estimates of cardiac output by identifying the magnitude of sources of error in 11 subjects with studies performed by two technicians and read by two readers. Analysis with generalizability theory demonstrated that the largest portion of the total variance was from differences among patients, with a smaller contribution due to day-to-day variability. Variability due to technician was low for continuous wave Doppler (2.0%), but high for pulsed wave (23.2%). Thus continuous wave, but not pulsed wave Doppler measurements, can be used to detect serial changes in cardiac output due to an intervention.

Doppler echocardiographic pulmonary venous flow-velocity pattern for assessment of the hemodynamic profile in acute congestive heart failure.

The hemodynamic profile of congestive heart failure (CHF) is best described in terms of its two primary sets of hemodynamic parameters, that is, left atrial pressure and cardiac output, each of which has a specific and independently variable hemodynamic cause. To assess whether analysis of the mitral and/or pulmonary venous flow-velocity patterns provides valuable information in the noninvasive assessment of the hemodynamic profile of CHF, these patterns were obtained by using the transthoracic approach in 18 patients with acute CHF with simultaneous measurements of catheter-derived mean pulmonary capillary wedge pressure and thermodilution cardiac index. Measurements were repeated on two occasions in each case: at the acute stage of CHF and 1 to 5 days after treatment. Peak diastolic pulmonary venous forward flow velocity was higher, the ratio of pulmonary venous systolic to diastolic peak forward flow velocity was lower, and the ratio of mitral early diastolic to late diastolic flow velocity was greater in patients with higher mean pulmonary capillary wedge pressure (r = 0.80, n = 36, p < 0.01; r = -0.69, n = 36, p < 0.01; r = 0.71, n = 36, p < 0.01). Peak systolic pulmonary venous forward flow velocity and time-velocity integral of the systolic pulmonary venous flow wave were greater in patients with larger cardiac index (r = 0.80, n = 36, p < 0.01; r = 0.62, n = 36, p < 0.01). In conclusion, two primary sets of hemodynamic parameters, that is, left atrial pressure and cardiac output, can be estimated with Doppler pulmonary venous flow parameters in patients with acute CHF.

Repeatability of measurements of pulmonary venous flow indices.

We investigated the measurement repeatability of four pulmonary venous flow indices. The indices were measured on 45 anonymised, transthoracic Doppler recordings of adequate technical quality. Measurements were taken by two independent observers, and repeated after 10 days. Plus/minus the repeatability coefficient, which was used to quantify repeatability, gives the 95% probability limits for random variation between repeated measurements. The index D-diff, which is the difference in duration of the pulmonary venous flow reversal during atrial systole and the transmitral A-wave, had repeatability coefficients of 50 and 57 ms intra- and inter-observer. For the fraction of antegrade pulmonary venous flow during ventricular systole, the coefficients were 12 and 13 percentage points, but improved to 6 and 7 among the high-quality recordings. The retrograde pulmonary venous flow during atrial systole as a fraction of the antegrade flow, had coefficients of 5 percentage points both intra- and inter-observer. The coefficient for the peak velocity of retrograde pulmonary venous flow was 0.05 m/s intra- and inter-observer. Thus, the systolic fraction was the only index that showed a satisfactory repeatability. We suggest that if the other indices are used, measurements should be taken by a blinded observer to avoid observer bias.