Left Ventricular Mass Influences Relationship Between Filling Pressure and Early-Diastolic Ratio of Inflow Velocity to Mitral Annular Velocity (E/e').

BACKGROUND: Early-diastolic mitral annular velocity (e') and the ratio of early-diastolic left ventricular (LV) inflow velocity (E) to e' (E/e') have been widely used as indexes of LV relaxation and filling pressure, respectively. However, many recent studies have demonstrated that they are not reliable in various clinical settings. We thus investigated the factors influencing these echocardiographic parameters in a multicenter study.Methods and Results:The study group comprised 69 patients, referred for cardiac catheterization, and enrolled in 5 university hospitals. Time constant (τ) and LV mean diastolic pressure (LVMDP) were measured using a micromanometer-tipped catheter. Although e' only weakly correlated with τ (r=-0.35, P<0.01), E/e' modestly correlated with LVMDP (r=0.48, P<0.001). Multivariable analysis revealed that hypertension (ß=-0.33, P<0.01) and LV ejection fraction (LVEF) (ß=0.44, P<0.001) were the independent determinants of e', and LV mass index (LVMI) (ß=0.37, P<0.001) and LVMDP (ß=0.47, P<0.001) were those of E/e'. Additionally, E/e' significantly correlated with LVMDP in patients with normal LVMI (r=0.74, P<0.001) but not in those with increased LVMI. CONCLUSIONS: The coincidence of hypertension and LVEF affected the relationship between LV relaxation and e', whereas LVMI altered the relationship between LV filling pressure and E/e'. Thus, clinical conditions associated with an increase in LVMI, such as LV hypertrophy and LV dilatation, should be considered when estimating the filling pressure from E/e'.

Quantitative distinction of the morphological characteristic of erythrocyte precursor cells with texture analysis using gray level co-occurrence matrix.

BACKGROUND: Morphological characteristics of blood cells are still qualitatively defined. So a texture analysis (Tx) method using gray level co-occurrence matrices (GLCMs; CM-Tx method) was applied to images of erythrocyte precursor cells (EPCs) for quantitatively distinguishing four types of EPC stages: proerythroblast, basophilic erythroblast, polychromatic erythroblast, and orthochromatic erythroblast. METHODS: Fifty-five images of four types of EPCs were downloaded from an atlas uploaded by the Blood Cell Morphology Standardization Subcommittee (BCMSS) of the Japanese Society of Laboratory Hematology (JSLH). Using in-house programs, two types of GLCMs-(R: d=1, θ=0°) and (U: d=1, θ=270°)-and nine types of texture distinction index (TDI) were calculated with images removed outer part of cell. RESULTS: Three binary decision trees were sequentially divided among four types of EPC with the sum average of GLCM (U), the contrast of GLCM (R), and the sum average of GLCM (U). The average concordance rate (sensitivity) of CM-Tx method with the judgments of eleven experts in the BCMSS of the JSLH was 95.8% (87.5-100.0), and the average specificity was 97.6% (92.5-100.0). CONCLUSIONS: The CM-Tx method is an effective tool for quantitative distinction of EPC with their morphological features.

Overestimation by echocardiography of the peak systolic pressure gradient between the right ventricle and right atrium due to tricuspid regurgitation and the usefulness of the early diastolic transpulmonary valve pressure gradient for estimating pulmonary artery pressure.

We investigated the influence of tricuspid regurgitation (TR) severity on the echocardiographic peak systolic transtricuspid pressure gradient (TRPG) and evaluated the usefulness of the peak early diastolic transpulmonary valve pressure gradient (PRPG) for estimating pulmonary artery (PA) pressure. In 55 consecutive right heart-catheterized patients, we measured the peak systolic right ventricular (RV)-right atrial (RA) pressure gradient (RV-RACATH), peak early diastolic PA-RV pressure gradient (PA-RVCATH), and mean PA pressure (MPAPCATH). Using echocardiography, we obtained the TRPG, PRPG, and an estimate of the mean PA pressure (EMPAP) as the sum of PRPG and the estimated RA pressure, and measured the vena contracta width of TR (VCTR). The difference between the TRPG and RV-RACATH was significantly greater in the very severe TR group (VCTR > 11 mm) than in the mild, moderate, and severe TR groups, and significantly greater in the severe TR group (7 < VCTR ≤ 11 mm) than in the mild TR group. The overestimation of the pressure gradient >10 mmHg by TRPG was not seen in the mild or moderate TR groups, but was observed in the severe and very severe TR groups (22 and 83%, respectively). In the ROC analysis, EMPAP could distinguish patients with MPAPCATH ≥ 25 mmHg with the area under the curve of 0.93, 100% sensitivity, and 87% specificity. In conclusion, TRPG frequently overestimated RV-RACATH when VCTR was >11 mm and sometimes did when VCTR was >7 mm, where EMPAP using PRPG was useful for estimating PA pressure.

Relationships of left ventricular strain and strain rate to wall stress and their afterload dependency.

Whether and how left ventricular (LV) strain and strain rate correlate with wall stress is not known. Furthermore, it is not determined whether strain or strain rate is less dependent on the afterload. In 41 healthy young adults, LV global peak strain and systolic peak strain rate in the longitudinal direction (LS and LSR, respectively) and circumferential direction (CS and CSR, respectively) were measured layer-specifically using speckle tracking echocardiography (STE) before and during a handgrip exercise. Among all the points before and during the exercise, all the STE parameters significantly correlated linearly with wall stress (LS: r = -0.53, p < 0.01, LSR: r = -0.28, p < 0.05, CS in the inner layer: r = -0.72, p < 0.01, CSR in the inner layer: r = -0.47, p < 0.01). Strain more strongly correlated with wall stress than strain rate (r = -0.53 for LS vs. r = -0.28 for LSR, p < 0.05; r = -0.72 for CS vs. r = -0.47 for CSR in the inner layer, p < 0.05), whereas the interobserver variability was similar between strain and strain rate (longitudinal 6.2 vs. 5.2 %, inner circumferential 4.8 vs. 4.7 %, mid-circumferential 7.9 vs. 6.9 %, outer circumferential 10.4 vs. 9.7 %), indicating that the differences in correlation coefficients reflect those in afterload dependency. It was thus concluded that LV strain and strain rate linearly and inversely correlated with wall stress in the longitudinal and circumferential directions, and strain more strongly depended on afterload than did strain rate. Myocardial shortening should be evaluated based on the relationships between these parameters and wall stress.

Characteristic systolic waveform of left ventricular longitudinal strain rate in patients with hypertrophic cardiomyopathy.

We analyzed the waveform of systolic strain and strain-rate curves to find a characteristic left ventricular (LV) myocardial contraction pattern in patients with hypertrophic cardiomyopathy (HCM), and evaluated the utility of these parameters for the differentiation of HCM and LV hypertrophy secondary to hypertension (HT). From global strain and strain-rate curves in the longitudinal and circumferential directions, the time from mitral valve closure to the peak strains (T-LS and T-CS, respectively) and the peak systolic strain rates (T-LSSR and T-CSSR, respectively) were measured in 34 patients with HCM, 30 patients with HT, and 25 control subjects. The systolic strain-rate waveform was classified into 3 patterns ("V", "W", and "√" pattern). In the HCM group, T-LS was prolonged, but T-LSSR was shortened; consequently, T-LSSR/T-LS ratio was distinctly lower than in the HT and control groups. The "√" pattern of longitudinal strain-rate waveform was more frequently seen in the HCM group (74 %) than in the control (4 %) and HT (20 %) groups. Similar but less distinct results were obtained in the circumferential direction. To differentiate HCM from HT, the sensitivity and specificity of the T-LSSR/T-LS ratio <0.34 and the "√"-shaped longitudinal strain-rate waveform were 85 and 63 %, and 74 and 80 %, respectively. In conclusion, in patients with HCM, a reduced T-LSSR/T-LS ratio and a characteristic "√"-shaped waveform of LV systolic strain rate was seen, especially in the longitudinal direction. The timing and waveform analyses of systolic strain rate may be useful to distinguish between HCM and HT.

Semi-Automatic Rating Method for Neutrophil Alkaline Phosphatase Activity.

BACKGROUND: The neutrophil alkaline phosphatase (NAP) score is a valuable test for the diagnosis of myeloproliferative neoplasms, but it has still manually rated. Therefore, we developed a semi-automatic rating method using Photoshop® and Image-J, called NAP-PS-IJ. METHODS: Neutrophil alkaline phosphatase staining was conducted with Tomonaga's method to films of peripheral blood taken from three healthy volunteers. At least 30 neutrophils with NAP scores from 0 to 5+ were observed and taken their images. From which the outer part of neutrophil was removed away with Image-J. These were binarized with two different procedures (P1 and P2) using Photoshop® . NAP-positive area (NAP-PA) and granule (NAP-PGC) were measured and counted with Image-J. RESULTS: The NAP-PA in images binarized with P1 significantly (P < 0.05) differed between images with NAP scores from 0 to 3+ (group 1) and those from 4+ to 5+ (group 2). The original images in group 1 were binarized with P2. NAP-PGC of them significantly (P < 0.05) differed among all four NAP score groups. The mean NAP-PGC with NAP-PS-IJ indicated a good correlation (r = 0.92, P < 0.001) to results by human examiners. CONCLUSIONS: The sensitivity and specificity of NAP-PS-IJ were 60% and 92%, which might be considered as a prototypic method for the full-automatic rating NAP score.

Left Ventricular Global Strain for Estimating Relaxation and Filling Pressure　- A Multicenter Study.

BACKGROUND: Speckle-tracking echocardiography (STE)-derived parameters may have better correlation with left ventricular (LV) relaxation and filling pressure than tissue Doppler-derived parameters. However, it has not been elucidated which parameter - strain or strain rate - and which direction of myocardial deformation - longitudinal or circumferential - is the most useful marker of LV relaxation and filling pressure. METHODS AND RESULTS: We conducted a prospective multicenter study and compared the correlation of tissue Doppler- and STE-derived parameters with the time constant of LV pressure decay (τ) and LV mean diastolic pressure (MDP) in 77 patients. The correlation of early-diastolic mitral annular velocity (e´) with τ was weak (r=-0.32, P<0.01), and that of peak longitudinal strain (LS) was the strongest (r=-0.45, P<0.001) among the STE-derived parameters. There was a modest correlation between LVMDP and the ratio of early-diastolic inflow velocity (E) to e´ (E/e´) (r=0.50, P<0.001). In contrast, the ratio of E to LS (E/LS) correlated strongly with LVMDP (r=0.70, P<0.001). The correlation of E/LS with LVMDP was significantly better than that for E/e´ (P<0.01). Receiver-operating characteristic analysis showed that E/LS had the largest area under the curve for distinguishing elevated LVMDP (E/LS 0.86, E/e´ 0.74, E/A 0.67). CONCLUSIONS: STE-derived longitudinal parameters correlated well with LV relaxation and filling pressure. In particular, E/LS could be more accurate than E/e´ for estimating LV filling pressure. (Circ J 2016; 80: 1163-1170).

Myocardial shortening in 3 orthogonal directions and its transmural variation in patients with nonobstructive hypertrophic cardiomyopathy.

BACKGROUND: Although longitudinal strain (LS) is known to be reduced in patients with hypertrophic cardiomyopathy (HCM), it has not been elucidated whether or not circumferential strain (CS) is reduced. We aimed to determine whether multidirectional and layer-specific myocardial strain is reduced in patients with nonobstructive HCM. METHODS AND RESULTS: Speckle-tracking echocardiography was performed in 41 HCM patients and 27 control subjects. Segmental and global LS and CS were measured in the inner, mid, and outer layers. Global LS was significantly lower in the HCM group than in controls in the inner (-10.3±2.9 vs. -14.8±2.0%, P<0.001), mid (-8.7±2.6 vs. -13.8±1.9%, P<0.001), and outer (-7.2±2.6 vs. -11.9±1.9%, P<0.001) layers. Global CS was preserved in the inner layer (-23.8±4.7 vs. -24.3±3.3%, P=0.69) but reduced in the mid (-10.3±3.1 vs. -13.3±2.5%, P<0.001) and outer layers (-6.7±2.3 vs. -8.6±2.3%, P=0.002). Differences in CS between the inner and outer layers correlated with segmental relative wall thickness (r=-0.20, P=0.002). Furthermore, only the absolute value of global CS in the inner layer positively correlated with left ventricular ejection fraction (r=0.32, P<0.01) among these multidirectional and layer-specific strains. CONCLUSIONS: In patients with HCM, not only the LS in all layers but also CS in the mid and outer layers was reduced, presumably reflecting impaired myocardial function. In contrast, CS in the inner layer was preserved, being associated with maintenance of chamber function.

Decreased aorto-septal angle may contribute to left ventricular diastolic dysfunction in healthy subjects.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is often observed in healthy older subjects without structural heart disease, although its exact mechanisms have not been established. A decrease in the aorto-septal angle (ASA), an alteration of LV shape due to aortic elongation, is also frequently seen in elderly subjects. The objective of this study was to evaluate whether it can contribute to LV diastolic dysfunction in healthy subjects. METHODS: Echocardiography was performed in 77 healthy subjects (42 men, mean age 43.2 ± 13.8 years) to measure the ASA, early diastolic transmitral flow velocity (E), isovolumic relaxation time (IRT), and early diastolic mitral annular velocity (e'). The LV peak early diastolic longitudinal strain rate (GSRE ) was measured using a two-dimensional speckle tracking imaging technique. RESULTS: ASA was significantly correlated with E (r = 0.54, p < 0.001), IRT (r = -0.41, p < 0.001), e' (r = 0.57, p < 0.001), and GSRE (r = 0.63, p < 0.001) and shown by stepwise multivariate analysis to be the strongest independent determinant of E, IRT, and GSRE , and one of the independent determinants of e'. CONCLUSIONS: The alteration of LV shape associated with reduced ASA may be one of the causes of LV diastolic dysfunction independently of age in otherwise healthy subjects.

Strain rate dispersion index can predict changes in left ventricular volume and adverse cardiac events following cardiac resynchronization therapy.

BACKGROUND: We previously reported that the strain rate dispersion index (SRDI), an index of left ventricular (LV) contractility loss because of mechanical dyssynchrony, better predicted the acute response to cardiac resynchronization therapy (CRT) than time-delay indices. However, it remains unclear whether the SRDI can predict the chronic response. Additionally, the SRDI needs to be simplified for use in clinical practice. METHODS AND RESULTS: Echocardiography was performed in 40 heart failure patients who underwent CRT. The SRDI, the average of segmental peak systolic strain rates minus global peak systolic strain rate, was calculated, together with strain-derived time-delay indices (St-SD) in the longitudinal, circumferential and radial directions using a speckle-tracking method. As simplified indices, the longitudinal parameters were calculated from the apical 4-chamber view in addition to 3 apical views. LV end-systolic volume (ESV) significantly decreased 6 months after CRT. Although circumferential St-SD and all SRDIs correlated with the changes in ESV (ΔESV), multivariate analysis revealed that the circumferential SRDI was the single independent determinant of ΔESV. During the 20±14 months after CRT, cardiac events occurred in 14 patients. Kaplan-Meier analyses revealed that all SRDIs were significant predictors of cardiac events whereas none of St-SDs was. CONCLUSIONS: The SRDI predicted the reduction in both LV volume and cardiac events after CRT better than time-delay indices. Additionally, a simplified SRDI could be as good a predictor of CRT response as the original.

New criteria for the sonographic diagnosis of a plaque ulcer in the extracranial carotid artery.

OBJECTIVE: The diagnostic power of carotid sonography in detecting plaque ulcers may be inadequate when using the conventional criteria. We aimed to evaluate the usefulness of new criteria that we devised through a preliminary analysis of 50 endarterectomy cases before the present series. SUBJECTS AND METHODS: Thirty carotid arteries of 30 consecutive patients who underwent endarterectomy (28 men; age range, 46-83 years) were studied. In the long- and short-axis B-mode images of carotid arteries, the concavity of the plaque surface and the surface echo intensity were carefully investigated. The conventional criteria stipulate a concavity larger than 2 × 2 mm with a well-defined back wall and flow reversal within the recess. Our new criteria specify a concavity in the plaque with the basal border echo weaker than that of the adjacent plaque surface, regardless of size. The final diagnosis was based on surgical and histologic findings. RESULTS: Among the 30 carotid arteries, 14 arteries had 14 ulcers at surgery. Seventeen concavities were detected by sonography, and 12 of them, including six smaller than 2 × 2 mm, were truly ulcers. Two concavities with an echo intensity of the basal border equal to or greater than that of the adjacent surface were not true ulcers. Only two of 14 ulcers were not detected by sonography. The sensitivity and specificity of the conventional criteria were 35.7% and 75.0%, respectively, and those of our new criteria were 85.7% and 81.3%, respectively. CONCLUSION: Our new criteria for the sonographic diagnosis of plaque ulcer are more useful than the conventional ones.

Difference in left atrial myocardial dynamics during reservoir phase between hypertrophic cardiomyopathy and hypertensive heart determined using three-dimensional speckle tracking echocardiography.

We aimed to investigate left atrial (LA) myocardial dynamics during reservoir phase using three-dimensional speckle-tracking echocardiography (3DSTE) focusing on its longitudinal-circumferential relationship in patients with left ventricular (LV) hypertrophy and clarifying the difference in LA myocardial reservoir dynamics between hypertrophic cardiomyopathy (HCM) and hypertension with LV hypertrophy (HT-LVH). We studied 4 age-matched groups consisting of 27 patients with HCM, 16 with HT-LVH, 22 hypertensive patients without LV hypertrophy (HT), and 18 normal controls. Using 3DSTE, we measured LA global longitudinal strain (LA-LSR), global circumferential strain (LA-CSR), and global area strain (LA-ASR) during the reservoir phase, as well as LV global longitudinal strain (LV-LS), global circumferential strain (LV-CS), and global area strain (LV-AS). LA-LSR was significantly lower in the HCM and HT-LVH groups than in the controls, but there was no significant difference between the HCM and HT-LVH groups. LA-CSR and LA-ASR were significantly lower in the HCM group than in the other three groups, among which no significant difference was detected. In all subjects, LA-LSR was significantly correlated with LV-LS but not with LV-CS. LA-CSR was correlated with neither LV-LS nor LV-CS. In conclusion, both longitudinal and circumferential LA myocardial expansion during reservoir phase were reduced in HCM, while only the longitudinal one was reduced in HT-LVH. Reduction of LA circumferential expansion may reflect a more serious and intrinsic impairment of LA myocardial distensibility in HCM. Measuring LA-CSR and LA-ASR using 3DSTE would contribute to a more accurate understanding of LA reservoir function abnormality in HCM.

Novel strain rate index of contractility loss caused by mechanical dyssynchrony. - A predictor of response to cardiac resynchronization therapy-.

BACKGROUND: Time-delay indexes are limited in predicting the response to cardiac resynchronization therapy (CRT), partly because they do not reflect the residual left ventricular (LV) contractility. We computed a novel index of LV contractility loss due to dyssynchrony (the strain rate (SR) dispersion index: SRDI) by using the speckle-tracking SR and compared the efficacy of the SRDI, time-delay indexes, and strain delay index (SDI), the previously reported index of wasted energy due to dyssynchrony, for predicting the acute response to CRT. METHODS AND RESULTS: Echocardiography was performed in 19 heart failure patients (LV ejection fraction (EF) 25 ± 6%) before and 2 weeks after CRT. The standard deviation of time to peak velocity, or strain, was calculated as time-delay indexes. The SRDI was calculated as the average of segmental peak systolic SR minus global peak systolic SR. Longitudinal SDI (L-SDI), longitudinal SRDI (L-SRDI), and circumferential SRDI (C-SRDI) significantly correlated with the change in global longitudinal strain (Δglobal LSt), whereas the time-delay indexes did not. Although the time-delay indexes were comparable between responders (Δglobal LSt ≥ 0.3%) and nonresponders, the L-SDI, L-SRDI, and C-SRDI were greater in responders. The area under the receiver operating characteristic curve of the L-SRDI, L-SDI, and C-SRDI for predicting responders was 0.89, 0.81, and 0.78, respectively. CONCLUSIONS: The SRDI correlated fairly well with an improvement in global LV systolic function after CRT.

Early diastolic mitral annular velocity at the interventricular septal annulus correctly reflects left ventricular longitudinal myocardial relaxation.

AIMS: Early diastolic mitral annular velocity (e') obtained by tissue Doppler imaging (TDI) is widely used to evaluate left ventricular (LV) diastolic function based on the assumption that it reflects myocardial relaxation in the long-axis direction. In this study, we aimed to determine whether or not e' truly reflects early diastolic longitudinal myocardial relaxation, and which is the most useful for evaluating LV diastolic function among e' measured at the interventricular-septal annulus (IS-e'), that measured at the lateral annulus (LW-e') or their mean value (M-e'). METHODS AND RESULTS: IS-e', LW-e', and M-e' were measured using colour TDI in 15 patients with hypertrophic cardiomyopathy, 13 patients with hypertension, and 19 control subjects. Using two-dimensional speckle-tracking imaging, early diastolic myocardial strain rates (SR(E)) were measured for the IS (IS-SR(E)), LW (LW-SR(E)), and entire LV myocardium (G-SR(E)). IS-e' was excellently correlated with IS-SR(E) (r = 0.90, P < 0.001); the correlation was better than that between LW-e' and LW-SR(E) (r = 0.75, P < 0.001). IS-e' and M-e' were well correlated with G-SR(E) (r = 0.88, P < 0.001 and r = 0.86, P< 0.001, respectively) and with LV early diastolic flow propagation velocity (FPV) (r = 0.77, P < 0.001 and r = 0.78, P < 0.001, respectively). The correlations of LW-e' to G-SR(E) (r = 0.80, P < 0.001) and FPV (r = 0.75, P < 0.001) did not reach this level. CONCLUSION: IS-e' well reflected LV longitudinal myocardial relaxation and LV diastolic function, and was found to be more useful in evaluating LV diastolic function than LW-e'.

Left ventricular global longitudinal strain calculated from manually traced endocardial border lengths utilizing the images for routine ejection fraction measurement by biplane method of disks.

PURPOSE: The purpose of this study was to test whether the fractional change in the endocardial border length between end-diastole and end-systole as manually traced in left ventricular ejection fraction (LVEF) measurement using the biplane method of disks (MOD) was consistent with the global longitudinal strain derived from speckle-tracking echocardiography. METHODS: For 105 patients who underwent echocardiography, two- and four-chamber images with manually traced endocardial lines for LVEF measurement by MOD were stored. LV endocardial lengths at end-diastole and at end-systole were measured on both images to calculate the fractional length changes, which were averaged (GLSMOD). Speckle-tracking analysis was performed to measure global longitudinal strains in the apical two- and four-chamber and long-axis images, and the three values were averaged (GLSSTE) according to the ASE and EACVI guidelines. RESULTS: There was no significant difference between GLSMOD and GLSSTE. GLSMOD correlated well with GLSSTE (r = 0.81, p < 0.001), and there was no fixed bias in the Bland-Altman analysis. The intraclass correlations for the intra- and inter-observer comparisons for GLSSTE were excellent, and those for GLSMOD were adequate. CONCLUSION: The fractional LV endocardial border length change, GLSMOD, showed sufficient agreement with GLSSTE to justify its use as a substitute for the STE-derived global longitudinal strain.

Angiotensin II receptor blocker, valsartan, increases myocardial blood volume and regresses hypertrophy in hypertensive patients.

BACKGROUND: Although a reduction in myocardial blood volume (MBV), an in vivo index of the myocardial microvasculature, measured by myocardial contrast echocardiography in patients with hypertension (HT), can be demonstrated, it is still unknown whether a decreased MBV can be improved by antihypertensive treatment. METHODS AND RESULTS: Eleven HT patients (mean age 58 years, 7 men) with left ventricular hypertrophy (LVH) and 10 age- and sex-matched normal controls were studied. Harmonic power Doppler images were acquired at end-diastole of every 6(th) beat and MBV was calculated as 10(X/10)x100%, where X (dB) is myocardial contrast intensity minus the contrast intensity of the adjacent intracavity blood pool. Baseline blood pressure (BP) and left ventricular mass index (LVMI) in the HT patients were higher and MBV was lower than in the controls (2.52 +/-0.37% vs 3.31 +/-0.61%, P<0.01). MBV did not correlate with mean BP, but was inversely correlated with LVMI (r=0.61, P<0.01). After treatment with valsartan for 6 months, LVMI significantly decreased and MBV increased (2.72 +/-0.26%, P<0.05 vs baseline) in the patients with HT. There was a significant inverse correlation between the changes in MBV and those of LVMI (r=0.62, P<0.05), but not between MBV and mean BP. CONCLUSIONS: Valsartan, an angiotensin II receptor blocker, corrected the decreased MBV in association with regression of LVH in patients with HT.

Right ventricular basal inflow and outflow tract diameters overestimate right ventricular size in subjects with sigmoid-shaped interventricular septum: a study using three-dimensional echocardiography.

Sigmoid-shaped ventricular septum (SS), a frequently encountered minor abnormality in echocardiographic examinations of the elderly, may have some influence on RV shape. We aimed to determine the influence of SS on the accuracy of the 6 RV linear diameter measurements in the light of three-dimensional echocardiographic (3DE) RV volume. The aorto-septal angle (ASA) was measured in the parasternal long-axis view using two-dimensional echocardiography (2DE) as an index of SS in 70 patients without major cardiac abnormalities who were subdivided into 35 with SS (ASA ≤ 120°) and 35 without SS (NSS). We measured RV end-diastolic volume (RVEDV) using 3DE; in addition, using 2DE, we measured basal RV diameter, mid-cavity diameter, longitudinal diameter and end-diastolic area in the apical four-chamber view; proximal RV outflow tract (RVOT) diameter in the parasternal long-axis view; and proximal and distal RVOT diameters in the parasternal short-axis view. RVEDV did not differ between the SS and NSS groups. The SS group had greater basal RV diameter and proximal and distal RVOT diameters than the NSS group. RV mid-cavity diameter, longitudinal diameter, and end-diastolic area did not differ between the groups. Among the 2DE parameters of RV size, RV end-diastolic area was most strongly correlated with RVEDV (r = 0.67), followed by RV mid-cavity diameter (r = 0.58). When SS is present, the echocardiographic basal RV diameter and RVOT diameters overestimate RV size, and the measurement of RV end-diastolic area and mid-cavity diameter more correctly reflect 3D RV volume.

Simple and noninvasive method to estimate right ventricular operating stiffness based on echocardiographic pulmonary regurgitant velocity and tricuspid annular plane movement measurements during atrial contraction.

It was recently shown that invasively determined right ventricular (RV) stiffness was more closely related to the prognosis of patients with pulmonary hypertension than RV systolic function. So far, a completely noninvasive method to access RV stiffness has not been reported. We aimed to clarify the clinical usefulness of our new echocardiographic index of RV operating stiffness using atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) and tricuspid annular plane movement during atrial contraction (TAPMAC). We studied 81 consecutive patients with various cardiac diseases who underwent echocardiography and cardiac catheterization. We measured PRPGDAC and TAPMAC using continuous-wave Doppler and M-mode echocardiography, respectively, and calculated PRPGDAC/TAPMAC. RV end-diastolic pressure (RVEDP) and RV pressure increase during atrial contraction (ΔRVPAC) were invasively measured, and RV volume change during atrial contraction (ΔVAC) was calculated from echocardiographic late-diastolic transtricuspid flow time-velocity integral and tricuspid annular area; thus ΔRVPAC/ΔVAC was used as the standard index for RV operating stiffness. PRPGDAC/TAPMAC well correlated with ΔRVPAC/ΔVAC (r = 0.84, p < 0.001) and RVEDP (r = 0.80, p < 0.001), and the area under the receiver operating characteristic curve to discriminate RVEDP > 12 mmHg was 0.94. Multivariate regression analysis revealed that PRPGDAC/TAPMAC was the single independent determinant of ΔRVPAC/ΔVAC (ß = 0.86, p < 0.001). PRPGDAC/TAPMAC is useful to estimate RV operating stiffness and a good practical indicator of RVEDP.

Correction to: Altered oscillation of Doppler-derived renal and renal interlobar venous flow velocities in hypertensive and diabetic patients.

In the original publication of this paper the legend of Fig. 1 should read as: Fig. 1 Pulsed Doppler flow velocity recordings of the aorta (a), right renal artery (b), right renal interlobar artery (c), inferior vena cava (d), right renal vein (e), and right renal interlobar vein (f). PSV peak systolic velocity, EDV end-diastolic velocity, V MAX maximum velocity, V MIN minimum velocity.

Novel echocardiographic method to assess left ventricular chamber stiffness and elevated end-diastolic pressure based on time-velocity integral measurements of pulmonary venous and transmitral flows.

Aims: The detection of increased left ventricular (LV) chamber stiffness may play an important role in assessing cardiac patients with potential but not overt heart failure. A non-invasive method to estimate it is not established. We investigated whether the echocardiographic backward/forward flow volume ratio from the left atrium (LA) during atrial contraction reflects the LV chamber stiffness. Methods and results: We studied 62 patients who underwent cardiac catheterization and measured their left ventricular end-diastolic pressure (LVEDP) and pressure increase during atrial contraction (ΔPa) from the LV pressure waveform. Using the echocardiographic biplane method of disks, we measured the LV volume change during atrial contraction indexed to the body surface area (ΔVa), and ΔPa/ΔVa was calculated as a standard for the LV operating chamber stiffness. Using pulsed Doppler echocardiography, we measured the time-velocity integral (TVI) of the backward pulmonary venous (PV) flow during atrial contraction (IPVA) and the ratio of IPVA to the PV flow TVI throughout a cardiac cycle (FPVA). We also measured the TVI of the atrial systolic forward transmitral flow (IA) and the ratio of the IA to the transmitral TVI during a cardiac cycle (FA) and calculated IPVA/IA and FPVA/FA. IPVA/IA and FPVA/FA were well correlated with ΔPa/ΔVa (r = 0.79 and r = 0.81) and LVEDP (r = 0.73 and r = 0.77). The areas under the ROC curve to discriminate LVEDP >18 mmHg were 0.90 for IPVA/IA and 0.93 for FPVA/FA. Conclusion: The FPVA/FA, the backward/forward flow volume ratio from the LA during atrial contraction, is useful for non-invasive assessments of LV chamber stiffness and elevated LVEDP.