Longitudinal left ventricular function in a population of healthy adults: a tissue Doppler imaging study.

BACKGROUND: Longitudinal left ventricular function is a major determinant of global ventricular function and is probably more sensitive than radial function in the detection of disease. Tissue Doppler imaging of the mitral annulus allows the study of longitudinal left ventricular function. METHODS: Forty-five healthy volunteers divided into two groups (younger and older than 45 years) were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 apical chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data. RESULTS: In contrast to the septal side, the lateral side of the annulus shows higher velocities and velocity-time integrals of the s and e waves, with non-significantly shorter isovolumic relaxation time and shorter time to peak e. There is functional agreement between the lateral and inferior sides versus the septal and anterior sides of the annulus. Most systolic parameters remained unchanged with aging; however, aging was associated with decreased e velocity, increased a velocity and inverted e/a ratio. The relation between s and fractional shortening also did not change with aging. Annular isovolumic contraction time and isovolumic relaxation time were shorter than their respective global time intervals. CONCLUSIONS: This study shows that there are physiological differences in velocities, time intervals and velocity-time integrals between the 4 sides of the mitral annulus, reflecting physiological heterogeneity and asynchrony, and that some of these parameters are age dependent. These data also contribute to a better understanding of longitudinal left ventricular function and may be useful in future studies as reference values in control groups.

Tissue Doppler imaging: clinical topics for the new millenium.

INTRODUCTION: Tissue Doppler imaging is an echocardiographic technique that allows the selective visualization and quantification of myocardial signals. Its aim is to complement the conventional Doppler study, adding more and better information on specific topics of cardiovascular diseases. During the first seven years of the technique, much scientific work was produced and some clinical applications of the method have emerged. CLINICAL APPLICATIONS: I--non ischemic heart disease: The technique has been widely used in diastology, in hypertrophic cardiomyopathy, in heart transplant patients and in arrhythmology. II--ischemic heart disease: The quantitative assessment of regional diastolic and systolic function makes the technique very promising during stress echocardiography and during percutaneous transluminal coronary angioplasty. CONCLUSIONS: In 2000, tissue Doppler echocardiography is still a young, exciting and promising technique. Despite the fact that much has already been done, there is still a long way to go, implying a great amount of time and personal investment. How often do we feel that we are building a small part of the future?

[Diastolic dysfunction and left ventricular hypertrophy in familial amyloidotic polyneuropathy: a cause-effect relationship?]. / Disfunção diastólica e hipertrofia ventricular esquerda na polineuropatia amiloidótica familiar: relação causa-efeito?

UNLABELLED: TTR Met30 Familial Amyloidotic Polyneuropathy of the Portuguese type (FAP) is an incapacitating and lethal hereditary disorder that affects predominantly young adults of both genders. Portuguese type FAP patients have sensory, motor and autonomic polyneuropathy. The generalised systemic amyloid infiltration involves the heart, leading to the characteristic granular bright sparkling echocardiographic pattern. LV wall thickening occurs in the late phases of the disease. LV diastolic dysfunction has been reported in the absence of systolic dysfunction; an abnormal diastolic transmitral flow pattern assessed by pulsed wave Doppler (PW) was described. PW is very much dependent on load conditions. Tissue Doppler imaging (TDI) has been used as a more reliable method to assess long axis diastolic function. OBJECTIVE: 1--To identify the incremental value of TDI in the assessment of diastolic function in FAP. 2--To correlate diastolic pattern abnormalities and left ventricular mass index (LVMI) in FAP patients. METHODS: We performed a prospective evaluation of 24 consecutive FAP patients and selected 14 (sinus rhythm, age < 45 years). Diastolic function was assessed by PW and classified as normal (GI-E/A > 1) or abnormal (GII-E/A < 1). TDI was performed in 4 sites of the mitral annulus (septum, lateral, inferior, anterior). Velocities of the rapid filling wave (E') and atrial contraction wave (A') were measured and E'/A' calculated. In each site we considered the TDI as normal (E'/A' > 1) or abnormal (E'/A' < 1). The LVMI was calculated by Devereux's formula. RESULTS: Age, gender and heart rate were similar in both groups. TDI at the septal mitral annulus was normal in all of the GI patients (E'/A': 1.29 +/- 0.19) and suggestive of abnormal LV relaxation in all of the GII patients (E'/A': 0.82 +/- 0.11, p < 0.0001). TDI revealed abnormal diastolic pattern when a restricted number of sites of the mitral annulus were assessed, even in GI patients and before PW abnormalities occurred. Fractional shortening (FS) and LVMI were similar in GI and GII (FS-GI: 45.5 +/- 5.3, GII 43.5 +/- 8.1%, p: NS; LVMI--GI: 66 +/- 9.3, GII: 67 +/- 3.0 g/m2 p: NS). CONCLUSION: The assessment of mitral annulus motion has introduced new data in the study of diastolic function of FAP patients. An abnormal LV relaxation pattern occurred early in the evolution of the disease in patients with normal LVMI and systolic function.

Tissue Doppler imaging in different locations of the mitral annulus: all different or all the same?

BACKGROUND: The assessment of the mitral annulus motion with tissue Doppler imaging is claimed to be an accurate method to quantify global left ventricular systolic and diastolic function. However, it is not yet perfectly defined which site of the annulus must be selected. Familial amyloidotic polyneuropathy of the Portuguese type (FAP) is an hereditary systemic disease in which diastolic dysfunction may occur. AIM: 1--To determine if in FAP patients the mitral annulus motion is independent of the selected site. 2--To compare pulsed wave Doppler parameters with tissue Doppler parameters in the different annular sites. METHODS: Of 24 FAP patients studied, 14 were included. In each patient we performed conventional transmitral pulsed wave Doppler and tissue Doppler in the 4 sites of the mitral annulus and measured the velocities of the rapid filling wave e, of the atrial contraction wave a and calculated e/a ratio. RESULTS: According to the transmitral inflow profile, patients were divided in 2 groups: Group I--normal global diastolic function and Group II--abnormal relaxation. Group I--33% of these patients showed e/a > 1 in the four sites and 67% showed e/a > 1 in at least 1, but not in all the sites. The rate of normal sites per patient was 3.1. Group II--25% of these patients showed e/a < 1 in the 4 sites of the annulus and 75% had e/a < 1 in at least 1, but not in all the sites analysed. The rate of abnormal sites/patient was 3.1. in this group. When conventional and tissue Doppler data were compared (bland and altman) the septal portion of the annulus was the one with the best correlation. CONCLUSIONS: 1--The assessment of the mitral annulus motion with tissue Doppler imaging is dependent on the site selected for study. 2--The septal site was the one that showed the highest correlation and concordance between pulsed wave Doppler and tissue Doppler. 3--The relative number of normal versus abnormal sites was determinant of the transmitral pattern. 4--Tissue Doppler imaging identified: a) among patients until now classified as normal diastolic function, a subgroup of patients with abnormal function in some sites of the annulus and b) among patients with abnormal relaxation, a subgroup with normal diastolic function in some sites of the annulus.

[Aortic peri-valvular abscess, mycotic aneurysm of Valsalva sinus, and fistula to the right ventricle in a context of acute infectious endocarditis]. / Abcesso peri-valvular aórtico, aneurisma micótico do seio de valsalva e fístula para o ventrículo direito no contexto de endocardite infecciosa aguda.

Infective endocarditis continues to attract the attention of many physicians. The authors present a case report of a 64 year old man with a history of infective endocarditis of a native aortic valve complicated by a perivalvular abscess, mycotic aneurysm of a sinus of valsalva and acquired aorta-right ventricular shunt.

Regional diastolic function in hypertrophic cardiomyopathy: a tissue Doppler echocardiographic study.

BACKGROUND: Tissue Doppler echocardiography (TDE) is a recent ultrasonic technique. One of its potential clinical uses is the assessment of regional diastolic function. OBJECTIVES: To compare left ventricular global diastolic function with interventricular septum regional diastolic function in patients with hypertrophic cardiomyopathy with different levels of global diastolic dysfunction. METHODOLOGY: 10 normal subjects (group 1), eight hypertrophic cardiomyopathy patients with abnormal relaxation (group 2) and 12 patients with hypertrophic cardiomyopathy with restrictive pattern (group 3) on the mitral inflow profile (pulsed wave Doppler) were studied. Each patient performed an M-mode color; TDE of the basal septum in the four chamber view. Velocities during the rapid filling phase (RF), and during atrial contraction (AC) were measured and RF/AC ratio calculated in each patient. RESULTS: While in normal subjects (group 1) the RF/AC ratio was always higher than 1, in patients with hypertrophic cardiomyopathy patients with different levels of global diastolic dysfunction (groups 2 and 3), the RF/AC ratio was always lower than 1 (velocities during atrial contraction always higher than during rapid filling), despite the level of global diastolic dysfunction. CONCLUSIONS: A ratio between myocardial velocities during the rapid filling phase and during atrial contraction lower than one (RF/AC < 1) is a tissue Doppler echocardiography index of regional diastolic dysfunction, independently of the severity of global diastolic dysfunction.

[Heart disease induced by mediastinal radiotherapy in Hodgkin's disease: report of a clinical case]. / Doença cardíaca induzida por radioterapia mediastínica na doença de Hodgkin: a propósito de um caso clínico.

As the number of adults surviving radiation therapy for Hodgkin's disease increases, the long-term clinical sequelae of such treatment is becoming increasingly more evident. Mediastinal radiation has been linked to acute and chronic pericarditis (with or without pleural effusion), coronary artery disease, myocardial fibrosis, valvular dysfunction and arrhythmias. The AA describe a case of a young patient with evidence of significant valvular disease following mediastinal irradiation, and review the radiation-induced cardiotoxicity, discussing aspects concerned with pathophysiology, diagnosis and therapy.

[The treatment of obstructive hypertrophic myocardiopathy refractory to medical therapy]. / Terapêutica da miocardiopatia hipertrófica obstrutiva refractária à terapêutica médica.

Until a few years ago, therapy of refractory Hypertrophic Obstructive cardiomyopathy was mainly surgical--Morrow's myotomy/myectomy or mitral valve replacement. Despite the good results of these techniques, they are not free of mortality and morbidity. In the last years a new and promising therapy has been developed: the Dual Chamber Pacemaker. Technically easier and less invasive than surgery, this therapy has achieved better results and lower mortality and morbidity during the follow-up.

[Tissue Doppler echocardiography: a new stage in the study of myocardial function]. / Ecocardiografia Doppler tecidular: uma nova etapa no estudo da função miocárdica.

Tissue Doppler echocardiography is a new technique that allows selective visualization and measurement of myocardial velocities, affording a new perspective on cardiac function. It has been showing promising and exciting preliminary results on coronary artery disease, hemodynamics, cardiomyopathies, right ventricular and aortic diseases and arrhythmias, opening a new era in the analysis of regional myocardial function.

[Acute and chronic sequential atrioventricular pacing in patients with obstructive-type hypertrophic myocardiopathy resistant to medical therapy]. / Electroestimulação aurículo-ventricular sequencial aguda e crónica em doentes portadores de miocardiopatia hipertrófica de tipo obstrutivo resistente à terapêutica médica.

An evaluation was undertaken regarding two female patients suffering from obstructive hypertrophic cardiomyopathy, with high and strongly symptomatic gradients, as well as evidencing a resistance to medication with beta-blockers, verapamil and disopyramide when administered in maximal doses. These patients were provided with the implant of a definitive type DDD pacemaker, with an auricular electrocatheter placed on the right auricular appendix, and with a bipolar ventricular catheter placed on the apex of the right ventricle. The generator was programmed with a short AV so as to ensure that the ventricular stimulation would at any given time be the result of the ventricular contraction would be initiated at the apex portion of the right ventricle. With these therapeutics, we observed not only a reduction or even the gradient, but also the complete elimination of the existing symptoms--angor, dyspnea, dizziness, palpitations and fainting--with the resulting normalcy of the quality of life of the patients. All taken into account we are of the opinion that these therapeutics are, in the case of patients suffering from obstructive hypertrophic cardiomyopathy, a valid alternative for surgical treatment by means of myectomy or myotomy, but without the morbidity and mortality rates presented by such methods.

[Acute juvenile myocardial infarct. A clinical case and review of the literature]. / Enfarte agudo do miocárdio juvenil. Caso clínico e revisão da literatura.

Authors report one case of myocardial infarction in a young man 23 years old. Prevalence of acute myocardial infarction under the age of 35-40 years is not negligible. Pathogenic mechanisms, risk factors, clinical presentation, prognosis, and findings in selective coronary angiography are reviewed.

[Sudden death in hypertrophic myocardiopathy]. / Morte súbita na miocardiopatia hipertrófica.

Sudden death is a very important event in the natural history of hypertrophic cardiomyopathy. Although its physiopathology is not still fully understood, there are several potential mechanisms to explain it, such as electrical, ischemic and hemodynamic events. It is thought that these mechanisms vary from patient to patient and that more than one mechanism may coexist in a specific patient. Risk factors for sudden death in hypertrophic cardiomyopathy are clinical, genetical and electrical. Risk stratification implies aggressive investigation (electrophysiological study and/or forearm plethysmography during exercise and/or tilt test) in order to identify the most probable mechanism involved in each case and to select individualized preventive measures (pharmacological, surgical, implantable cardioverter defibrillator). The role of amiodarone is still controversial because of contradictory results with this drug in this illness.