Can left ventricular diastolic stiffness be measured noninvasively?

doi:10.1067/mje.2002.121196

Journal of the American Society of Echocardiography

Volume 15, Issue 9, September 2002, Pages 935-943

https://doi.org/10.1067/mje.2002.121196 Get rights and content

Abstract

Background: A noninvasive estimation of left ventricular (LV) diastolic chamber stiffness (K_LV) is still a challenge. Experimental data suggests that K_lv can be obtained by using Doppler mitral flow deceleration time (DT) as the only variable: K_lv = (70/[DT−20])² mm Hg/mL. We assessed the accuracy of this noninvasive estimate of K_lv by comparing it with invasive measurement of K_lv in intact patients with a wide range of LV size and function under varying loading conditions. Methods: Twenty-five patients (age 54 ± 12 years) with ischemic heart disease (n = 19) or primary LV dysfunction (n = 6), with a wide range of DT (79-324 ms) and ejection fraction (8%-57%), underwent simultaneous assessment of LV pressure by micromanometer and volume by 2-dimensional (2D) echocardiogrpahy-guided Doppler mitral flow velocity (where volume = mitral flow velocity integral × annular area) calibrated to 2D echocardiography stroke volume. Invasive K_lv [delta pressure (from minimum to end-diastolic)/delta volume (during the same time interval)] was obtained at baseline and in 23 patients after LV unloading by prostaglandin E₁ (30-60 ng/kg/min) (n = 12), nitroglycerin (0.2 mg) (n = 9) or magnesium (1 g) (n = 2). Noninvasive K_lv was estimated according to the above formula. Results: In this set of patients with normal mitral annular area (3.9 ± 1.1 cm²/m²), multivariate analysis showed that DT is inversely related to K_lv (P <.001) but not to left atrial chamber stiffness, LV volume, relaxation time constant, mitral valve opening pressure, or area. The relation between noninvasively calculated and directly measured K_lv was close to the line of identity under all conditions, (y = 0.93x + 0.05, r = 0.67, n = 48, P <.001), although with a wide standard error of the estimate (0.26 mm Hg/mL). Conclusion: We conclude that K_lv can be calculated ± 0.5 mm Hg/mL from noninvasively measured DT in patients. (J Am Soc Echocardiogr 2002;15:935-43.)

Section snippets

Patients

Six patients (mean ± SD) age 53.7 ± 4.8 years, with primary dilated cardiomyopathy (ejection fraction 24.2% ± 11.6%) and 19 patients (55.9 ± 6.8 years) with ischemic heart disease (13 with a previous myocardial infarction, ejection fraction 32.5% ± 15.6%; and 6 with angina pectoris, ejection fraction 47.2% ± 8.7%) formed the study population (Table 1).All patients were in sinus rhythm and none of them had clinical or echocardiographic evidence of aortic regurgitation. Secondary mitral

Results

The correlation coefficent between the angiographic and the echocardiographic volumes was r = 0.91 (y = 0.85x − 0.95, P <.001, SEE = 25 mL/m²) (Figure 2).

. Plot of estimates of left ventricular (LV) volumes, as assessed at left ventriculography and 2-dimensional echocardiography (top), and of average between 2 methods compared with their difference (bottom). There is highly significant correlation between 2 techniques. Prediction intervals (95%) are also shown. SEE, Standard error of estimate.

Discussion

This study demonstrates in patients with a variety of LV sizes and ejection fractions and under varying loading conditions, but with a narrow and normal range of mitral annular areas, that DT of early diastolic mitral valve flow velocity is determined by K_LV and is not significantly influenced by MVO pressure, K_la, mitral area, ventricular systolic volume, or the rate of LV relaxation. Thus, K_LV can be estimated from a Doppler echocardiographic measurement of mitral flow velocity DT. This is

Conclusion

In conclusion, this study demonstrates that DT is predominately determined by K_LV and not significantly influenced by K_la, mitral opening pressure, LV systolic volume or relaxation in intact patients under a variety of conditions. Thus, K_LV can be assessed from a noninvasively measured DT.

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Cited by (38)

Feasibility and limitations of mitral valve repair, with or without left ventricular reconstruction in non-ischemic dilated cardiomyopathy
2018, Journal of Cardiology
Although non-transplant surgical interventions for non-ischemic dilated cardiomyopathy (NIDCM) are relatively effective, their feasibility and limitations have not been fully elucidated. The aim of this study was to define the feasibility and limitations of mitral valve repair, with or without surgical ventricular reconstruction for patients with NIDCM in terms of postoperative low cardiac output syndrome (LOS).
Twenty non-transplant candidates (aged 57 ± 13 years) with NIDCM and significant mitral regurgitation had undergone mitral valve repair combined with submitral procedures. Using a 72-mL plastic ellipsoidal sizer, left ventricular reconstruction was performed concomitantly in 14/20 (70%) patients with extremely large ventricles. Total stroke volume, deceleration time of early trans-mitral flow wave, and the slope (Mw) in the preload recruitable stroke-work relationship were assessed using transthoracic echocardiography. LOS was defined as in-hospital death due to heart failure or a cardiac index less than 2.2 L/min/m² before discharge.
There were three in-hospital deaths and four patients with postoperative cardiac index less than 2.2 L/min/m² [n = 7 (35%), LOS group]. Preoperative total stroke volume, deceleration time, and the Mw were significantly lower in the LOS group compared to those in the non-LOS group; the predicted cut-off values for LOS were 84 mL/beat (p = 0.008), 133 ms (p = 0.015), and 45 erg cm⁻³ × 10³ (p = 0.036), respectively. Preoperative left ventricular ejection fraction and ventricular size could not predict postoperative LOS. The one-year survival rate was 0% in the LOS group and 84% in the non-LOS group (p < 0.001).
Mitral valve repair, with or without left ventricular reconstruction, could be contraindicated for NIDCM patients with low total stroke volume, deceleration time, and Mw in terms of high postoperative incidence of LOS. For high-risk patients, other therapeutic strategies might be necessary.
Increased Left Ventricular Diastolic Stiffness Is Associated With Heart Failure Symptoms in Aortic Stenosis Patients With Preserved Ejection Fraction
2017, Journal of Cardiac Failure
Clinical risk factors associated with heart failure (HF) symptoms in aortic stenosis (AS) patients with preserved ejection fraction (EF) have not been fully identified. We hypothesized that left ventricular (LV) diastolic stiffness is associated with HF symptoms in patients with AS.
We retrospectively evaluated 275 patients with at least moderate AS (aortic valve area <1.5 cm²) and preserved EF (≥50%). LV diastolic stiffness was evaluated with the use of echocardiographic parameters, diastolic wall strain (DWS, a measure of LV wall stiffness), and K_LV (a marker of LV chamber stiffness). There were 69 patients with HF. Patients with HF were older, were more likely to be African American, had a higher body mass index, and had more hypertension and coronary artery disease (P < .05 for all). Aortic valve area index and mean pressure gradient across the aortic valve were not different between patients with and without HF. Despite similar echocardiographic parameters of AS severity, patients with HF had stiffer LV (DWS 0.21 ± 0.06 vs 0.25 ± 0.06 [P < .01], K_LV 0.17 ± 0.11 vs 0.13 ± 0.08 [P < .01]). Logistic regression analyses revealed that after adjusting for age, race, body mass index, history of hypertension, and coronary artery disease, LV diastolic stiffness parameters remained significantly associated with HF symptoms.
LV diastolic stiffness is independently associated with HF in AS patients with preserved EF.
Non-invasively estimated left atrial stiffness is associated with short-term recurrence of atrial fibrillation after electrical cardioversion
2017, Journal of Cardiology
Citation Excerpt :
Mitral deceleration time, taken as an index of diastolic function, was measured as the time interval between peak E wave and the zero intercept of the deceleration profile. LV stiffness (Klv) was also quantified, according to the following equation (Klv = 1.28exp[−0.008×mitral deceleration time]) that had been previously validated by invasive methods in a group of cardiomyopathic patients [14]. LA longitudinal strain was assessed by using a two-dimensional speckle-tracking technique from standard gray-scale loops [15].
As atrial stiffness (K_la) is an important determinant of cardiac pump function, better mechanical characterization of left atrial (LA) cavity would be clinically relevant. Pulmonary venous ablation is an option for atrial fibrillation (AF) treatment that offers a powerful context for improving our understanding of LA mechanical function. We hypothesized that a relation could be detected between invasive estimation of K_la and new non-invasive deformation parameters and traditional LA and left ventricular (LV) function descriptors, so that K_la can be estimated non-invasively. We also hypothesized that a non-invasive surrogate of K_la would be useful in predicting AF recurrence after cardioversion.
In 20 patients undergoing AF ablation, LA pressure–volume curves were derived from invasive pressure and echocardiographic images; K_la was calculated during ascending limb of V-loop as ΔLA pressure/ΔLA volume. 2D-speckle-tracking echocardiographic LA and LV longitudinal strains and volumes, ejection fraction (EF) and ventricular stiffness (K_lv), as obtained from mitral deceleration time, were tested as non-invasive K_la predictors. In 128 sinus rhythm patients 1 month after electrical cardioversion for persistent AF, non-invasively estimated K_la (computed-K_la) was tested as predictor of recurrence at 6 months.
Tertiles of mean LA pressure correlated with increasing K_la (trend, p = 0.06) and decreasing LA peak strain, LVEF, and LV longitudinal strain (p = 0.029, p = 0.019, and p = 0.024). There were no differences in LA and LV volumes and K_lv across groups. Multiple regression analysis identified LV longitudinal strain as the only independent predictor of K_la (p = 0.014). Patients in highest quartile of computed-K_la (estimated as [log] = 0.735 + 0.051 × LV strain) tended to have highest AF recurrence rate (25%) as compared with remaining 3 quartiles (9%, 9%, 3%, p = 0.09).
K_la can be assessed invasively in patients undergoing AF ablation and it can be estimated non-invasively using LV strain. AF recurrence after cardioversion tends to be highest in highest quartile of computed-K_la.
Diastolic dysfunction in cardiomyopathies
2011, Journal of Cardiovascular Echography
Citation Excerpt :
However, because of the obvious limitations of the invasive approach, a non-invasive haemodynamic assessment by echo-Doppler study has become the clinical routine. A comprehensive evaluation of LV diastolic (dys)function is possible by the combined assessment of transmitral, pulmonary venous and tissue Doppler (TDI) curves4,10–13. Additional information can be obtained by evaluation of left atrial dimensions and pulmonary arterial systolic pressure in presence of a Doppler signal of tricuspid regurgitation4,14.
Cardiomyopathies are diseases of the heart muscle, with frequent genetic component, characterized by a strong heterogeneity concerning clinical presentation and echocardiographic profile. Diastolic dysfunction can affect all forms of cardiomyopathy, often being an expression of a more advanced state of the disease.
To analyze the role of diastolic dysfunction in cardiomyopathies.
Echo-Doppler analysis is therefore very helpful, as it may give important information concerning the clinical stage of disease progression and could provide a prognostic stratification tool in order to orient the clinician toward early specific treatment.
Le cardiomiopatie sono malattie del muscolo cardiaco, a frequente componente genetica, caratterizzate da una forte eterogeneità per quanto concerne sia la presentazione clinica sia il profilo ecocardiografico. La disfunzione diastolica può interessare tutte le forme di cardiomiopatia, essendo spesso espressione di uno stato più avanzato di malattia.
Analizzare il ruolo della disfuzione diastolica nelle cardiomiopatie.
L’analisi mediante eco-Doppler è di fondamentale importanza, in quanto può essere foriera di importanti informazioni riguardanti lo stadio clinico di progressione di malattia, potendo fornire uno strumento di stratificazione prognostica capace di orientare precocemente il clinico verso trattamenti più aggressivi.
Prognostic importance of a restrictive transmitral filling pattern in patients with symptomatic congestive heart failure and atrial fibrillation
2009, American Heart Journal
Restrictive diastolic filling pattern is associated with increased mortality in patients with myocardial infarction and heart failure. Most studies have excluded patients with atrial fibrillation. The aim of the present study was to assess the prognostic value of a restrictive filling pattern in patients with atrial fibrillation.
Doppler echocardiography including pulsed wave Doppler assessment of transmitral flow was performed in 880 patients with a clinical diagnosis of heart failure on hospital admission. Filling was considered restrictive when the mitral deceleration time ≤140 milliseconds.
On admission, 337 (39%) of the patients had atrial fibrillation. Among patients in atrial fibrillation, 170 (50%) had a restrictive filling; and in patients in sinus rhythm, 256 (47%) had restrictive filling (P = .34). During follow-up of median 6.7 years (range 5.3-7.8), 564 patients died (64%). Mortality was significantly higher in patients with a restrictive filling pattern irrespective of atrial fibrillation or sinus rhythm (P < .001). In a multivariable model only including patients in atrial fibrillation, a restrictive filling pattern remained a significant predictor of all-cause mortality (hazard ratio 1.79, 95% CI 1.24-2.58, P =.002).
In a heterogeneous population hospitalized for symptomatic heart failure, a restrictive transmitral filling pattern during hospitalization is an ominous prognostic sign also in patients presenting with atrial fibrillation.
Clinical Relevance of Echocardiography in Acute Severe Dyspnea
2009, Journal of the American Society of Echocardiography
Citation Excerpt :
Garcia et al8 showed a good correlation between PCWP and E/Vp in a population hospitalized in an ICU, but Vp is also known to take longer to record, with a lower recording success rate and higher interobserver variability.10,11 In our study, E/EDT appeared to be a good parameter to predict elevated LV pressure.15,16 Recently, Traversi et al17 demonstrated that the E-wave deceleration rate was closely correlated with PCWP (r = 0.75) in a population with dilated cardiomyopathy and systolic dysfunction.
The aim of this study was to assess the most relevant echocardiographic parameter for the clinical diagnosis of acute dyspnea due to left-heart dysfunction.
Transthoracic echocardiography was performed in 88 patients in sinus rhythm admitted for respiratory distress. Two experts determined the cause of dyspnea as cardiogenic (26 patients) or noncardiogenic (62 patients).
The feasibility was 100% for the E/A ratio and the E/E deceleration time (EDT) ratio but 97%, 89%, and 85% for the E/Ea ratio, left ventricular ejection fraction (LVEF), and the E/propagation velocity (Vp) ratio, respectively. The area under the receiver operating characteristic curve for E/EDT (0.947 ± 0.035) was statistically significantly greater than that for E/A (0.753 ± 0.068) (P = .004). The areas under the curves for all other parameters were not statistically significantly different. In the subpopulation of patients with LVEFs > 45%, the area under the curve for LVEF was significantly smaller than those for E/Ea, E/EDT, and E/Vp.
E/EDT, E/Ea, and E/Vp appear equally useful to distinguish acute dyspnea due to left-heart dysfunction from that of pulmonary origin. However, E/EDT and E/Ea can be considered the best indices with regard to feasibility.

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^*: Reprint requests: Prof Paolo Marino, FESC, Servizio Aggregato di Cardiologia, Ospedale Policlinico, P.le L.A. Scuro 10, 37134 Verona, Italy (E-mail: [email protected]).

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Original ArticlesCan left ventricular diastolic stiffness be measured noninvasively?*

Abstract

Section snippets

Patients

Results

Discussion

Conclusion

Prog Cardiovasc Dis

Am Heart J

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Mechanism of altered patterns of left ventricular filling during the development of congestive heart failure

Circulation

Determination of left ventricular chamber stiffness from the time for deceleration of early left ventricular filling

Circulation

Estimation of left ventricular operating stiffness from Doppler early filling deceleration time in humans

Am J Physiol Heart Circ Physiol

Loading manipulations improve the prognostic value of Doppler evaluation of mitral flow in patients with chronic heart failure

Circulation

Does prostaglandin E1 infusion affect the left ventricular filling pattern of end-stage dilated cardiomyopathy? A combined hemodynamic-echo Doppler study

J Cardiovasc Pharmacol

Measurement of ventricular volumes, ejection fraction, mass, wall stress, and regional wall motion

Original Articles
Can left ventricular diastolic stiffness be measured noninvasively?*