Assessment of subendocardial contractile function in aortic stenosis: a study using speckle tracking echocardiography.

BACKGROUND: Angina and an electrocardiographic strain pattern are potential manifestations of subendocardial ischemia in aortic stenosis (AS). Left ventricular (LV) twist is known to increase proportionally to the severity of AS, which may be a result of loss of the inhibiting effect of the subendocardial fibers due to subendocardial dysfunction. It has also been shown that the ratio of LV twist to circumferential shortening of the endocardium (twist-to-shortening ratio [TSR]) is a reliable parameter of subendocardial dysfunction. The aim of this study was to investigate whether these markers are increased in AS patients with angina and/or electrocardiographic strain. METHODS: The study comprised 60 AS patients with an aortic valve area <2.0 cm(2) and LV ejection fraction >50%, and 30 healthy-for age and gender matched-control subjects. LV rotation parameters were determined by speckle tracking echocardiography. RESULTS: Comparison of patients without angina and strain (n = 22), with either angina or strain (n = 28), and with both angina and strain (n = 8), showed highest peak systolic LV apical rotation, peak systolic LV twist, and TSR, in patients with more signs of subendocardial ischemia. In a multivariate linear regression model, only severity of AS and the presence of angina and/or strain could be identified as independent predictors of peak systolic LV twist and TSR. CONCLUSIONS: Peak systolic LV twist and TSR are increased in AS patients and related to the severity of AS and symptoms (angina) or electrocardiographic signs (strain) compatible with subendocardial ischemia.

Assessment of subclinical atherosclerosis using contrast-enhanced ultrasound.

AIMS: The sensitivity of standard carotid ultrasound and colour Doppler for the detection of subclinical atherosclerotic plaques is suboptimal. The aim of this study is to assess whether contrast-enhanced ultrasound (CEUS) added to standard carotid ultrasound improves the detection of subclinical atherosclerosis. METHODS AND RESULTS: Carotid intima-media thickness (CIMT) measurement, standard carotid ultrasound including colour Doppler imaging, and CEUS were performed in 100 asymptomatic patients with one or more risk factors for atherosclerosis. CEUS was performed using intravenous administration of SonoVue™ contrast agent (Bracco S.p.A., Milan, Italy). CIMT, standard ultrasound, colour Doppler, and CEUS were reviewed by two independent observers. Standard ultrasound, colour Doppler, and CEUS were scored for the presence of atherosclerotic plaques. Subclinical atherosclerosis was diagnosed if patients had a CIMT above their age-corrected threshold value or if atherosclerotic plaques were present on standard carotid ultrasound clips or CEUS clips. McNemar's test was performed to compare between groups. Twenty-one patients (21%) had a thickened CIMT value and were considered to have subclinical atherosclerosis. Standard carotid ultrasound including colour Doppler demonstrated atherosclerotic plaques in 77 patients (77%). The addition of CEUS to the standard ultrasound protocol demonstrated atherosclerotic plaques in 88 patients (88%). The incorporation of CEUS into the standard carotid ultrasound protocol resulted in a significantly improved detection of patients with subclinical atherosclerosis (P < 0.01). CONCLUSION: CEUS has an incremental value for the detection of subclinical atherosclerosis in the carotid arteries. Atherosclerotic plaques which were only detected with CEUS and not with standard carotid ultrasound and colour Doppler imaging were predominantly hypoechoic.

New Scores for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography.

Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheter-based balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by two-dimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.

Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography.

BACKGROUND: The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). METHODS: A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. RESULTS: In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. CONCLUSION: The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Assessment of mitral annular velocities by speckle tracking echocardiography versus tissue Doppler imaging: validation, feasibility, and reproducibility.

BACKGROUND: Mitral annular velocity may be measured angle independently by speckle tracking echocardiography (STE), in contrast with tissue Doppler imaging (TDI). The purpose of the current study was to compare STE and TDI, with respect to 1) the accuracy of velocity measurements in a moving phantom, 2) the feasibility and reproducibility of measurement of mitral annular velocities in a clinical setting, and 3) the estimation of left ventricular filling pressures using mitral annular velocities. METHODS: The velocity of a moving phantom, using different angles of insonation, and mitral annular velocities of 80 nonselected patients and 50 healthy volunteers were determined using TDI and STE. A subgroup of 20 patients was studied during right-sided heart catheterization. RESULTS: When the motion direction of the phantom was parallel to the ultrasound beam, both TDI and STE determined velocities accurately. With increasing angle of insonation, TDI-derived velocity decreased, whereas STE-derived velocity remained unchanged. The feasibility of mitral annular velocities measured by TDI and STE was comparable (98% vs 95%, P = not significant). Although for both techniques correlations between measured mitral annular velocities at repeated examinations were good, the test-retest variability of mitral annular velocities by TDI was higher. E/Em ratio by STE correlated better to pulmonary capillary wedge pressure (R(2) = 0.51, P < .001) compared with E/Em ratio derived from TDI (R(2) = 0.35, P < .01), although the difference in correlation was not statistically significant because of the limited sample size. CONCLUSION: Tissue velocities can be accurately determined by STE in a moving phantom and are angle independent, in contrast with TDI measurements. Furthermore, STE is a feasible and better reproducible method for the assessment of mitral annular velocities in a clinical setting.

Importance of transducer position in the assessment of apical rotation by speckle tracking echocardiography.

BACKGROUND: Speckle tracking echocardiography is increasingly used to quantify left ventricular (LV) twist. However, one of the limitations of the assessment of LV twist by speckle tracking echocardiography is the crucial dependence on correct acquisition of a LV apical short-axis. This study sought to assess the influence of transducer position on LV apical rotation measurements. METHODS: The study population consisted of 58 consecutive healthy volunteers (mean age 38 +/- 13 years, 25 men). To obtain parasternal short-axis images at the LV apical level, the following protocol was used. From the standard parasternal position (LV and aorta most inline, with the mitral valve tips in the middle of the sector) an as-circular-as-possible short-axis image of the LV apex, just proximal to the level with end-systolic LV luminal obliteration, was obtained by angulation of the transducer (position 1). From this position, the position of the transducer was changed to one (position 2) and two (position 3) intercostal spaces more caudal with subsequent similar transducer adaptations. RESULTS: In 8 volunteers (14%) parasternal image quality was insufficient for speckle tracking echocardiography. In 13 volunteers (22%) the LV apical short-axis could only be obtained from one transducer position. In the remaining volunteers with two (n = 27) or three (n = 10) available transducer positions, a more caudal transducer position was associated with increased measured LV apical rotation. Mean measured LV apical rotation was 5.2 +/- 1.8 degrees at position 1, 7.3 +/- 2.6 degrees at position 2 (P < .001), and 8.7 +/- 2.2 degrees at position 3 (P < .001 vs position 1 and P < .05 vs position 2). CONCLUSION: A more caudal transducer position is associated with increased measured LV apical rotation.

Assessment of left atrial volume and function by real-time three-dimensional echocardiography.

BACKGROUND: Determination of left atrial (LA) size and function is important in clinical decision-making. Calculation of LA volume (LAV) is the most accurate index of LA size. AIM: To compare real-time 3-dimensional echocardiography (RT3DE) and 2-dimensional echocardiography (2DE) for calculation of LAV and function. METHODS: Fifty patients were studied using 2DE and RT3DE for calculating LAV including: Maximum (V max), minimum (V min) and pre-atrial contraction (V pre A) volumes. For 2DE, the formula: LAV=8(A1) (A2)/3pi (L) was used, while for RT3DE, offline analysis was performed using commercially available software. LA function indices including Total Atrial Stroke Volume (TASV), active ASV (AASV), Total Atrial Emptying Fraction (TAEF), active AEF (AAEF), passive AEF (PAEF), and Atrial Expansion Index (AEI) were calculated. RESULTS: Patients were classified into 2 equal groups: group I with normal V max (< 50 ml) and group II with V max (> or = 50 ml). Good correlation was obtained between RT3DE and 2DE for LAV (r=0.64, p=0.001) in group I and (r=0.83, p<0.0001) in group II. In group I, LAV and functions showed no significant difference by both techniques, while in group II, the V min and V pre A were significantly lower by RT3DE than 2DE (p=0.009, 0.006). TAEF, AEI, and PAEF indices were significantly higher by RT3DE than 2DE in group II. CONCLUSION: RT3DE provides a reproducible assessment of active and passive LA function by volumetric cyclic changes. It is comparable and may be superior to 2DE due to its higher sensitivity to volume changes.

Assessment of left ventricular ejection fraction after myocardial infarction using contrast echocardiography.

AIMS: Despite its relatively high intra- and inter-observer variability for left ventricular ejection fraction (LV-EF) echocardiography is clinically still the most used modality to assess LV-EF. We studied whether adding a second-generation microbubble contrast agent could decrease this variability. METHODS AND RESULTS: Forty-eight patients underwent transthoracic echocardiography in second-harmonic mode (SHI) with and without contrast within 5 days after an acute myocardial infarction. LV-EF was determined using the Simpson's biplane method. With contrast intra-observer variability decreased from 12.5 +/- 11.5% to 7.0 +/- 7.0% (P < 0.001) and inter-observer variability decreased from 16.9 +/- 9.9% to 7.0 +/- 6.2% (P < 0.001). Bland-Altman analysis confirmed these findings by demonstrating smaller 95% limits of agreement for both the intra- and inter-observer variability when contrast was used. This improvement in intra- and inter-observer variability was seen to a comparable extent in patients with moderate-to-poor and good quality SHI echocardiograms. CONCLUSION: Echo contrast significantly improves intra- and inter-observer variability for LV-EF, both in patients with moderate-to-poor and good quality SHI echocardiograms.

Assessment of left atrial ejection force in hypertrophic cardiomyopathy using real-time three-dimensional echocardiography.

The study included 30 patients with hypertrophic cardiomyopathy (HCM) (obstructive and nonobstructive) and 15 control subjects. End-diastolic mitral annulus area (MAA(3D)) and mitral valve area (MVA(3D)) were measured by real-time 3-dimensional (3D) echocardiography. MVA(2D) and peak mitral inflow A wave velocity (V) were measured by 2-dimensional (2D) echocardiography. Left atrial ejection force (LA-EF) was calculated by 2D echocardiography and real-time 3D echocardiography using the formula: 0.5 x 1.06 x (MAA or MVA) x V2, where (1.06) is blood viscosity. LA-EF(2D-MVA), LA-EF(3D-MVA), LA-EF(3D-MAA), and V were significantly higher in patients with HCM than control subjects (P < .001). LA-EF(2D-MVA) and LA-EF(3D-MVA) were lower than LA-EF(3D-MAA) in HCM only (P < .001). In obstructive HCM, LA-EF(2D-MVA), LA-EF(3D-MVA), LA-EF(3D-MAA), and V were significantly higher than in nonobstructive HCM (P < .05). Left ventricular outflow tract gradient contributed independently to high LA-EF in obstructive HCM. We concluded that HCM is associated with higher LA-EF than normal, and higher in obstructive HCM than nonobstructive indicating a higher atrial workload that is reflected by LA-EF(3D-MAA).

Assessment of mitral annulus size and function by real-time 3-dimensional echocardiography in cardiomyopathy: comparison with magnetic resonance imaging.

OBJECTIVE: We sought to assess mitral annular (MA) size and function in hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) using real-time 3-dimensional (3D) echocardiography (RT3DE). METHODS: The study included 30 patients with HCM, 20 patients with DCM, and 30 control subjects. RT3DE measurements included end-systolic and end-diastolic MA area (MAA) (MAA(3D)), MA diameter(3D), MA fractional area change (MAFAC), and MA fractional shortening. In subgroup of 50 patients, magnetic resonance imaging (MRI) was used for MAA(MRI) and MA diameter(MRI) measurement. RESULTS: End-diastolic MAA(3D) was larger in HCM than in control group (P < .0001). Higher MAFAC and MA fractional shortening were present in HCM than in control group (P = .001 and P = .006, respectively). End-systolic and end-diastolic MAA(3D) in DCM were higher than in HCM and control groups (P < .0001). Lower MAFAC and MA fractional shortening were present in DCM than in HCM and control groups (P < .0001). MAFAC correlated well with left ventricular function in control subjects (r = 0.94, P < .0001), whereas correlation was less in DCM (r = 0.53, P = .02) and HCM (r = 0.42, P < .01). RT3DE and MRI measurements were comparable. CONCLUSION: RT3DE assessment of MA size and function in control subjects and patients with cardiomyopathy is accurate and well correlated with MRI.

Assessment of intravascular and extravascular mechanisms of myocardial perfusion abnormalities in obstructive hypertrophic cardiomyopathy by myocardial contrast echocardiography.

OBJECTIVES: To assess mechanisms of myocardial perfusion impairment in patients with hypertrophic cardiomyopathy (HCM). METHODS: Fourteen patients with obstructive HCM (mean (SD) age 53 (10) years, 11 men) underwent intravenous adenosine myocardial contrast echocardiography (MCE), positron emission tomography (PET) and cardiac catheterisation. Fourteen healthy volunteers (mean age 31 (4) years, 11 men) served as controls. Relative myocardial blood volume (rBV), exchange flow velocity (beta), myocardial blood flow (MBF), MBF reserve (MFR) and endocardial-to-subepicardial (endo-to-epi) MBF ratio were measured from the steady state and contrast replenishment time-intensity curves. RESULTS: Patients with HCM had lower rest MBF (for LVRPP-corrected)--mean (SD) (0.92 (0.12) vs 1.13 (0.25) ml/min/g, p<0.01)--and hyperaemic MBF--(2.56 (0.49) vs 4.34 (0.78) ml/min/g, p<0.01) than controls. Resting rBV was lower in patients with HCM (0.094 (0.016) vs 0.138 (0.014) ml/ml), and during hyperaemia (0.104 (0.018) ml/ml vs 0.185 (0.024) ml/ml) (all p<0.001) than in controls. beta tended to be higher in HCM at rest (9.4 (4.6) vs 7.7 (4.2) ml/min) and during hyperaemia (25.8 (6.4) vs 23.1 (6.2) ml/min) than in controls. Septal endo-to-epi MBF decreased during hyperaemia (0.86 (0.15) to 0.64 (0.18), p<0.01). rBV was inversely correlated with left ventricular (LV) mass index (p<0.05). Both hyperaemic and endo-to-epi MBF were inversely correlated with LV end-diastolic pressure, LV mass index, and LV outflow tract pressure gradient (all p<0.05). MCE-derived MBF correlated well with PET at rest (r = 0.84) and hyperaemia (r = 0.87) (all p<0.001). CONCLUSIONS: In patients with HCM, LV end-diastolic pressure, LV outflow tract pressure gradient, and LV mass index are independent predictors of rBV and hyperaemic MBF.

Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography.

BACKGROUND: The tricuspid valve (TV) is a complex structure. Unlike the aortic and mitral valve it is not possible to visualize all TV leaflets simultaneously in one cross-sectional view by standard two-dimensional echocardiography (2DE) either transthoracic or transesophageal due to the position of TV in the far field. AIM: Quantitative and qualitative assessment of the normal TV using real-time 3-dimensional echocardiography (RT3DE). METHODS: RT3DE was performed for 100 normal adults (mean age 30 +/- 9 years, 65% males). RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Measurements included TV annulus diameters (TAD), TV area (TVA), and commissural width. RESULTS: In 90% of patients with good 2DE image quality, it was possible to analyse TV anatomy by RT3DE. A detailed anatomical structure including unique description and measurement of tricuspid annulus shape and size, TV leaflets shape, and mobility, and TV commissural width were obtained in majority of patients. Identification of each TV leaflet as seen in the routine 2DE views was obtained. CONCLUSION: RT3DE of the TV is feasible in a large number of patients. RT3DE may add to functional 2DE data in description of TV anatomy and providing highly reproducible and actual reality (anatomical and functional) measurements.

Value of assessment of tricuspid annulus: real-time three-dimensional echocardiography and magnetic resonance imaging.

AIM: To detect the accuracy of real-time three-dimensional echocardiography (RT3DE) and two-dimensional echocardiography (2DE) for tricuspid annulus (TA) assessment compared with magnetic resonance imaging (MRI). METHODS: Thirty patients (mean age 34 +/- 13 years, 60% males) in sinus rhythm were examined by MRI, RT3DE, and 2DE for TA assessment. End-diastolic and end-systolic TA diameter (TAD) and TA fractional shortening (TAFS) were measured by RT3DE, 2DE, and MRI. End-diastolic and end-systolic TA area (TAA) and TA fractional area changes (TAFAC) were measured by RT3DE and MRI. End-diastolic and end-systolic right ventricular (RV) volumes and ejection fraction (RV-EF) were measured by MRI. RESULTS: The TA was clearly delineated in all patients and visualized as an oval-shaped by RT3DE and MRI. There was a good correlation between TAD(MRI) and TAD(3D) (r = 0.75, P = 0.001), while TAD(2D) was fairly correlated with TAD(3D) and TAD(MRI) (r = 0.5, P = 0.01 for both). There were no significant differences between RT3DE and MRI in TAD, TAA, TAFS, and TAFAC measurements, while TAD(2D) and TAFS(2D) were significantly underestimated (P < 0.001). TAFS(2D) was not correlated with RV-EF, while TAFS(3D) and TAFAC(3D) were fairly correlated with RV-EF (r = 0.49, P = 0.01, and r = 0.47, P = 0.02 respectively). CONCLUSION: RT3DE helps in accurate assessment of TA comparable to MRI and may have an important implication in the TV surgical decision-making processes. RT3DE analysis of TA function could be used as a marker of RV function.

Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography.

AIM: Assessment of pulmonary valve (PV) and right ventricular outflow tract (RVOT) using real-time 3-dimensional echocardiography (RT3DE). METHODS: Two-dimensional echocardiography (2DE) and RT3DE were performed in 50 patients with congenital heart disease (mean age 32 +/- 9.5 years, 60% female). Measurements were obtained at parasternal views: short axis (PSAX) at aortic valve level and long axis (PLAX) with superior tilting. RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Diameters of PV annulus (PVAD), and RVOT (RVOTD) were measured by both 2DE and RT3DE, while areas (PVAA) and (RVOTA) by RT3DE only. RESULTS: By RT3DE, PV was visualized sufficiently in 68% and RVOT excellently in 40%. PVAD and PVAA were measured in 88%. RVOTD and PVAD by 2DE at PLAX were significantly higher than PSAX (P < 0.0001) and lower than that by RT3DE (P < 0.001). CONCLUSION: RT3DE helps in RVOT and PV assessment adding more details supplemental to 2DE.

Assessment of tricuspid valve annulus size, shape and function using real-time three-dimensional echocardiography.

Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making process. Obviously, 2-dimensional transthoracic echocardiography (2D TTE) is limited in TA visualization due to its complex 3D shape. The study aimed to determine TA morphology, size and function with real-time three-dimensional echocardiography (RT3DE) in 40 patients divided into two equal groups (I: normal TA and II: dilated). 2D TTE measurements included TA diameter (TAD) at apical 4-chamber (AP4CH) and parasternal short axis (PSAX) views. RT3DE measurements included TA area (TAA), major TAD and minor TAD. TA fractional shortening (TAFS), and TA fractional area change (TAFAC) were calculated from end-systolic and end-diastolic measurements. RT3DE allowed visualization and measurement of the entire oval-shaped TA in all patients irrespective of its size (normal or dilated). 2D TTE measurement of TAD at both AP4CH and at PSAX views was significantly smaller than the major TAD measured by RT3DE (P<0.0001) and nearly matched with the minor TAD in all patients. Calculation of TAFS was comparable with both techniques. TAFAC was significantly higher than TAFS (P<0.0001). So, RT3DE could be relied on more accurately than 2D TTE in the assessment of TA size and function which may aid in decision-making and selection of proper surgical procedure when indicated.

Preload dependence of new Doppler techniques limits their utility for left ventricular diastolic function assessment in hemodialysis patients.

Left ventricular (LV) hypertrophy leads to diastolic dysfunction. Standard Doppler transmitral and pulmonary vein (PV) flow velocity measurements are preload dependent. New techniques such as mitral annulus velocity by Doppler tissue imaging (DTI) and LV inflow propagation velocity measured from color M-mode have been proposed as relatively preload-independent measurements of diastolic function. These parameters were studied before and after hemodialysis (HD) with ultrafiltration to test their potential advantage for LV diastolic function assessment in HD patients. Ten patients (seven with LV hypertrophy) underwent Doppler echocardiography 1 h before, 1 h after, and 1 d after HD. Early (E) and atrial (A) peak transmitral flow velocities, peak PV systolic (s) and diastolic (d) flow velocities, peak e and a mitral annulus velocities in DTI, and early diastolic LV flow propagation velocity (V(p)) were measured. In all patients, the E/A ratio after HD (0.54; 0.37 to 1.02) was lower (P < 0.01) than before HD (0.77; 0.60 to 1.34). E decreased (P < 0.01), whereas A did not. PV s/d after HD (2.15; 1.08 to 3.90) was higher (P < 0.01) than before HD (1.80; 1.25 to 2.68). Tissue e/a after HD (0.40; 0.26 to 0.96) was lower (P < 0.01) than before HD (0.56; 0.40 to 1.05). Tissue e decreased (P < 0.02), whereas a did not. V(p) after HD (30 cm/s; 16 to 47 cm/s) was lower (P < 0.01) than before HD (45 cm/s; 32 to 60 cm/s). Twenty-four hours after the initial measurements values for E/A (0.59; 0.37 to 1.23), PV s/d (1.85; 1.07 to 3.38), e/a (0.41; 0.27 to 1.06), and V(p) (28 cm/s; 23 to 33 cm/s) were similar as those taken 1 h after HD. It is concluded that, even when using the newer Doppler techniques DTI and color M-mode, pseudonormalization, which was due to volume overload before HD, resulted in underestimation of the degree of diastolic dysfunction. Therefore, the advantage of these techniques over conventional parameters for the assessment of LV diastolic function in HD patients is limited. Assessment of LV diastolic function should not be performed shortly before HD, and its time relation to HD is essential.