Optimal left ventricular diameter measurement in subjects with sigmoid septum: comparison with three-dimensional left ventricular volume.

BACKGROUND: The purpose of this study was to determine the most appropriate measurement of left ventricular (LV) end-diastolic diameter for subjects with the sigmoid septum (SS) by measuring the LV end-diastolic diameter at the base and mid-ventricle and by examining the relationship between these measurements and the three-dimensional (3D) echocardiographic LV end-diastolic volume. METHODS: In 91 patients who underwent echocardiography for screening cardiovascular abnormalities, the aorto-septal angle (ASA) was measured as an index of the sigmoid septum. LV end-diastolic diameter was measured at the base and mid-ventricular level (DDbase and DDmid, respectively), and their average value was calculated (DDavg). By using 3D echocardiography, LV end-diastolic volume (EDV3D) was measured. RESULTS: Among 91 patients, 48 patients had narrow ASA (< 120 degrees) and were divided into the sigmoid septum (SS) group, and the remaining 43 patients were divided into the non-SS group. In the SS group, all DDbase, DDmid, and DDavg were significantly correlated with EDV3D (r = 0.59, 0.80, and 0.76, respectively), and the correlation coefficient between DDbase and EDV3D was significantly lower than that between DDmid and EDV3D (p < 0.01). On the other hand, in the non-SS group, all DDbase, DDmid, and DDavg were significantly correlated with EDV3D (r = 0.77, 0.85, and 0.84, respectively), and the correlation coefficient between DDbase and EDV3D was statistically comparable to that between DDmid and EDV3D (p = 0.12). ASA was significantly correlated with the difference of DDmid minus DDbase (r = - 0.71, p < 0.001). CONCLUSIONS: In patients with SS, DDmid and DDavg were well reflected the 3D echocardiographic LV end-diastolic volume.

Paradoxical increase in global longitudinal strain by handgrip exercise despite left ventricular diastolic dysfunction.

BACKGROUND: Although global longitudinal strain (GLS) is recognized as a sensitive marker of intrinsic left ventricular (LV) dysfunction, its afterload dependency has also been pointed. We hypothesized that decrease in GLS during handgrip exercise could be more sensitive marker of intrinsic myocardial dysfunction. METHODS: Handgrip exercise-stress echocardiography was performed in 90 cardiovascular disease patients with preserved LV ejection fraction. LV diastolic function was graded according to the guidelines. Diastolic wall stress (DWS) and ratio of left atrial (LA) volume index to late-diastolic mitral annular velocity (LAVI/a') were measured at rest as LV stiffness. As well, LA strains were measured to assess LA function. GLS was expressed as absolute value and significant changes in GLS by handgrip exercise was defined as changes over prespecified mean absolute test-retest variability (2.65%). RESULTS: While mean value of GLS did not change by the exercise, substantial patients showed significant changes in GLS: decreased (group I, n = 28), unchanged (group II, n = 34), and increased (group III, n = 28). Unexpectedly, patients in group I did not show any clinical and echocardiographic characteristics, while those in group III were characterized by elevated natriuretic peptide levels, blunted heart rate response to handgrip exercise, and advanced LV diastolic dysfunction. Multivariable analyses revealed that DWS, left atrial booster strain, and grade II or more diastolic dysfunction determined the increase in GLS even after adjustment for elevated natriuretic peptides and the changes in heart rate by the exercise. CONCLUSION: In contrast to our hypothesis, paradoxical increase in GLS by handgrip exercise could be associated with advanced LV diastolic dysfunction in cardiovascular patients with preserved LV ejection fraction. Our findings suggest that HG exercise for heart failure patients does not enhance the afterload straightforward, resulting in variable changes of GLS according to the individual conditions.

Application of an echocardiographic scoring system of left ventricular filling pressure to diagnose acute heart failure in patients complaining dyspnea.

BACKGROUND: Dyspnea is a common symptom in acute heart failure (AHF) patients. Although an accurate and rapid diagnosis of AHF is essential to improve prognosis, estimation of left ventricular (LV) filling pressure (FP) remains challenging, especially for noncardiologists. We evaluated the usefulness of a recently-proposed parameter of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, to detect AHF in patients complaining of dyspnea. METHODS: Echocardiography and lung ultrasonography (LUS) were performed in 121 consecutive patients (68 ±â€¯14 years old, 75 males) presenting with dyspnea. The VMT score was determined from the atrioventricular valve opening phase (tricuspid valve first: 0, simultaneous: 1, mitral valve first: 2) and inferior vena cava dilatation (absent: 0, present: 1), and VMT ≥2 was judged as positive. LUS was performed with the 8 zones method and judged as positive if 3 or more B-lines were observed in bilateral regions. The AHF diagnosis was performed by certified cardiologists according to recent guidelines. RESULTS: Of the 121 patients, 33 were diagnosed with AHF. The sensitivity and specificity for diagnosing AHF were 64 % and 84 % for LUS and 94 % and 88 % for VMT score. In logistic regression analysis, VMT score showed a significantly higher c-index than LUS (0.91 vs 0.74, p = 0.002). In multivariable analyses, VMT score was associated with AHF independently of clinically relevant covariates and LUS. In addition, serial assessment of VMT score followed by LUS provided a diagnostic flow chart to diagnose AHF (VMT 3: AHF definitive, VMT 2 and LUS positive: AHF highly suspicious; VMT 2 and LUS negative: further investigation is needed; VMT ≤ 1: AHF rejected). CONCLUSIONS: VMT score showed high diagnostic accuracy in diagnosing AHF. Combined assessment of the VMT score and LUS could become a reliable strategy for diagnosis of AHF by non-cardiologists.

Impact of right ventricular stiffness on discordance between hemodynamic parameter and regurgitant volume in patients with pulmonary regurgitation.

BACKGROUND: Accurate detection of significant pulmonary regurgitation (PR) is critical in management of patients after right ventricular (RV) outflow reconstruction in Tetralogy of Fallot (TOF) patients, because of its influence on adverse outcomes. Although pressure half time (PHT) of PR velocity is one of the widely used echocardiographic markers of the severity, shortened PHT is suggested to be seen in conditions with increased RV stiffness with mild PR. However, little has been reported about the exact characteristics of patients showing discrepancy between PHT and PR volume in this population. METHODS: Echocardiography and cardiac magnetic resonance imaging (MRI) were performed in 74 TOF patients after right ventricular outflow tract (RVOT) reconstruction [32 ± 10 years old]. PHT was measured from the continuous Doppler PR flow velocity profile and PHT < 100 ms was used as a sign of significant PR. Presence of end-diastolic RVOT forward flow was defined as RV restrictive physiology. By using phase-contrast MRI, forward and regurgitant volumes through the RVOT were measured and regurgitation fraction was calculated. Significant PR was defined as regurgitant fraction ≥ 25%. RESULTS: Significant PR was observed in 54 of 74 patients. While PHT < 100 ms well predicted significant PR with sensitivity of 96%, specificity of 52%, and c-index of 0.72, 10 patients showed shortened PHT despite regurgitant fraction < 25% (discordant group). Tricuspid annular plane systolic excursion and left ventricular (LV) ejection fraction were comparable between discordant group and patients showing PHT < 100 ms and regurgitant fraction ≥ 25% (concordant group). However, discordant group showed significantly smaller mid RV diameter (30.7 ± 4.5 vs. 39.2 ± 7.3 mm, P < 0.001) and higher prevalence of restrictive physiology (100% vs. 42%, P < 0.01) than concordant group. When mid RV diameter ≥ 32 mm and presence of restrictive physiology were added to PHT, the predictive value was significantly improved (sensitivity: 81%, specificity: 90%, and c-index: 0.89, P < 0.001 vs. PHT alone by multivariable logistic regression model). CONCLUSION: Patients with increased RV stiffness and non-enlarged right ventricle showed short PHT despite mild PR. Although it has been expected, this was the first study to demonstrate the exact characteristics of patients showing discrepancy between PHT and PR volume in TOF patients after RVOT reconstruction.

Usefulness of the pulmonary venous flow waveform for assessing left atrial stiffness.

PURPOSE: This study investigated the novel non-invasive left atrial (LA) stiffness parameter using pulmonary venous (PV) flow measurements and the clinical usefulness of the novel LA stiffness parameter. METHODS: We retrospectively analyzed 237 patients who underwent right heart catheterization and echocardiography less than one week apart. From the pulmonary artery wedge pressure waveform, the difference between x-descent and v-wave (ΔP) was measured. Using the echocardiographic biplane method of disks, the difference between LA maximum volume and that just before atrial contraction (ΔVMOD) was calculated, and the ΔP/ΔVMOD was calculated as a standard LA stiffness index. From the PV flow waveform, the peak systolic velocity (S), peak diastolic velocity (D), and minimum velocity between them (R) were measured, and S/D, S/R, and D/R were calculated. From the speckle tracking echocardiography-derived time-LA volume curve, the difference between LA maximum volume and that just before atrial contraction (ΔVSTE) was measured. Each patient's prognosis was investigated until three years after echocardiography. RESULTS: Among the PV flow parameters, D/R was significantly correlated with ΔP (r = 0.62), and the correlation coefficient exceeded that between S/D and ΔP (r = - 0.39) or S/R and ΔP (r = 0.14). The [D/R]/ΔVSTE was significantly correlated with ΔP/ΔVMOD (r = 0.61). During the follow-up, 37 (17%) composite endpoints occurred. Kaplan-Meier analysis showed that patients with [D/R]/ΔVSTE greater than 0.13 /mL were at higher risk of cardiac events. CONCLUSION: The [D/R]/ΔVSTE was useful for assessing LA stiffness non-invasively and might be valuable in the prognostic evaluation of patients with cardiac diseases.

Associations of right ventricular pulsatile load and cardiac power output to clinical outcomes in heart failure: Difference from systemic circulation.

BACKGROUND: Although left ventricular (LV) cardiac power output (CPO) is a powerful prognostic indicator in heart failure (HF), the significance of right ventricular (RV) CPO is unknown. In contrast, RV pulsatile load is a key prognostic marker in HF. We investigated the impact of RV-CPO and pulsatile load on cardiac outcome and the prognostic performance of the combined systemic and pulmonary circulation parameters in HF. METHODS: Right heart catheterization and echocardiography were performed in 231 HF patients (62 ±â€¯16 years, LV ejection fraction 42 ±â€¯18 %). Invasive and noninvasive CPOs were calculated from mean systemic or pulmonary arterial pressure and cardiac output. LV-CPO was then normalized to LV mass (LV-P/M). Pulmonary arterial capacitance and the ratio of acceleration time to ejection time (AcT/ET) of RV outflow were used as parameters of RV pulsatile load. The primary endpoints, defined as a composite of cardiac death, HF hospitalization, ventricular arrythmia, and LVAD implantation after the examination, were recorded. RESULTS: Noninvasive CPOs were moderately correlated with invasive ones (LV: ρ = 0.787, RV: ρ = 0.568, and p < 0.001 for both). During a median follow-up period of 441 days, 57 cardiovascular events occurred. Lower LV-P/M and higher RV pulsatile load were associated with cardiovascular events; however, RV-CPO was not associated with the outcome. Echocardiographic LV-P/M and AcT/ET showed significant incremental prognostic value over the clinical parameters. CONCLUSIONS: RV pulsatile load assessed by AcT/ET may be a predictor of clinical events in HF patients. The combination of echocardiographic LV-P/M and AcT/ET could be a novel noninvasive prognostic indicator in HF patients.

Determinants of exercise capacity in patients with heart failure without left ventricular hypertrophy.

BACKGROUND: Determinants of exercise intolerance in a phenotype of heart failure with preserved ejection fraction (HFpEF) with normal left ventricular (LV) structure have not been fully elucidated. METHODS: Cardiopulmonary exercise testing and exercise-stress echocardiography were performed in 44 HFpEF patients without LV hypertrophy. Exercise capacity was determined by peak oxygen consumption (peak VO2). Doppler-derived cardiac output (CO), transmitral E velocity, systolic (LV-s') and early diastolic mitral annular velocities (e'), systolic pulmonary artery (PA) pressure (SPAP), tricuspid annular plane systolic excursion (TAPSE), and peak systolic right ventricular (RV) free wall velocity (RV-s') were measured at rest and exercise. E/e' and TAPSE/SPAP were used as an LV filling pressure parameter and RV-PA coupling, respectively. RESULTS: During exercise, CO, LV-s', RV-s', e', and SPAP were significantly increased (p < 0.05 for all), whereas E/e' remained unchanged and TAPSE/SPAP was significantly reduced (p < 0.001). SPAP was higher and TAPSE/SPAP was lower at peak exercise in patients showing lower-half peak VO2. In univariable analyses, LV-s' (R = 0.35, p = 0.022), SPAP (R = -0.40, p = 0.008), RV-s' (R = 0.47, p = 0.002), and TAPSE/SPAP (R = 0.42, p = 0.005) were significantly correlated with peak VO2. In multivariable analyses, not only SPAP, but also TAPSE/SPAP independently determined peak VO2 even after the adjustment for clinically relevant parameters. CONCLUSIONS: In HFpEF patients without LV hypertrophy, altered RV-PA coupling by exercise could be associated with exercise intolerance, which might not be caused by elevated LV filling pressure.

Clinical Utility of Superior Vena Cava Flow Velocity Waveform Measured from the Subcostal Window for Estimating Right Atrial Pressure.

BACKGROUND: The superior vena cava (SVC) flow velocity waveform from the supraclavicular window reflects right atrial pressure (RAP) status. Recent guidelines have stated that the subcostal window is an alternative view for recording SVC flow, but the validity of this approach remains unclear. The aim of this study was to determine the usefulness of SVC flow evaluation from the subcostal window for estimating RAP. METHODS: Differences in SVC flow characteristics between opposite approaches were examined in 38 healthy adults. In 115 patients with cardiovascular diseases who underwent cardiac catheterization and echocardiography within 48 hours, the ratio of peak systolic to diastolic forward SVC flow (SVC-S/D) was measured, and the diagnostic ability of SVC-S/D for elevated RAP was tested. A validation cohort was used to confirm the diagnostic ability of SVC-S/D in 48 patients who underwent both cardiac catheterization and echocardiography within 24 hours. In 59 patients in the derivation and validation cohorts, the relationship between SVC flow and RAP was compared between the opposite windows. RESULTS: Both systolic and diastolic SVC flow velocities were higher in the subcostal than in the supraclavicular approach, and effect of position change on subcostal SVC-S/D was smaller than that on supraclavicular SVC-S/D in healthy adults. Measurement of SVC-S/D from the subcostal window was feasible in 98 patients (85%). RAP was inversely correlated with SVC-S/D (r = -0.50, P < .001) and was an independent determinant of SVC-S/D after adjustment for right ventricular systolic function (ß = -0.48, P < .001). A cutoff value of 1.9 for SVC-S/D showed 85% sensitivity and 74% specificity in identifying elevated RAP. Additionally, SVC-S/D showed an incremental diagnostic value combined with inferior vena cava size and collapsibility (P = .006). When a cutoff value of SVC-S/D < 1.9 was applied to the validation cohort, it showed acceptable accuracy of 72% and incremental diagnostic value combined with inferior vena cava parameters (P = .033). SVC-S/D from the subcostal window correlated better with RAP than that from the supraclavicular window (P < .001, Meng's test). CONCLUSIONS: Measurement of SVC flow velocity from the subcostal window was feasible, and SVC-S/D from the subcostal window could be an additive parameter for estimating RAP.

Determinants of altered left ventricular suction in pre-capillary pulmonary hypertension.

AIMS: Although the left ventricular (LV) dysfunction in pre-capillary pulmonary hypertension (PH) has been recently recognized, the mechanism of LV dysfunction in this entity is not completely understood. We thus aimed to elucidate the determinants of intraventricular pressure difference (IVPD), a measure of LV suction, in pre-capillary PH. METHODS AND RESULTS: Right heart catheterization and echocardiography were performed in 86 consecutive patients with pre-capillary PH (57 ± 18 years, 85% female). IVPD was determined using colour M-mode Doppler to integrate the Euler equation. In overall, IVPD was reduced compared to previously reported value in normal subjects. In univariable analyses, QRS duration (P = 0.028), LV ejection fraction (P = 0.006), right ventricular (RV) end-diastolic area (P < 0.001), tricuspid annular plane systolic excursion (P = 0.004), and LV early-diastolic eccentricity index (P = 0.009) were associated with IVPD. In the multivariable analyses, RV end-diastolic area and LV eccentricity index independently determined the IVPD. CONCLUSION: Aberrant ventricular interdependence caused by RV enlargement could impair the LV suction. This study first applied echocardiographic IVPD, a reliable marker of LV diastolic suction, to investigate the mechanism of LV diastolic dysfunction in pre-capillary PH.

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.

Prognostic value of an echocardiographic index reflecting right ventricular operating stiffness in patients with heart failure.

PURPOSE: We recently reported a noninvasive method for the assessment of right ventricular (RV) operating stiffness that is obtained by dividing the atrial-systolic descent of the pulmonary artery-RV pressure gradient (PRPGDAC) derived from the pulmonary regurgitant velocity by the tricuspid annular plane movement during atrial contraction (TAPMAC). Here, we investigated whether this parameter of RV operating stiffness, PRPGDAC/TAPMAC, is useful for predicting the prognosis of patients with heart failure (HF). METHODS: We retrospectively included 127 hospitalized patients with HF who underwent an echocardiographic examination immediately pre-discharge. The PRPGDAC/TAPMAC was measured in addition to standard echocardiographic parameters. Patients were followed until 2 years post-discharge. The endpoint was the composite of cardiac death, readmission for acute decompensation, and increased diuretic dose due to worsening HF. RESULTS: 58 patients (46%) experienced the endpoint during follow-up. Univariable and multivariable Cox regression analyses demonstrated that the PRPGDAC/TAPMAC was associated with the endpoint. In a Kaplan-Meier analysis, the event rate of the greater PRPGDAC/TAPMAC group was significantly higher than that of the lesser PRPGDAC/TAPMAC group. In a sequential Cox analysis for predicting the endpoint's occurrence, the addition of PRPGDAC/TAPMAC to the model including age, sex, NYHA functional classification, brain natriuretic peptide level, and several echocardiographic parameters including tricuspid annular plane systolic excursion significantly improved the predictive power for prognosis. CONCLUSION: A completely noninvasive index of RV operating stiffness, PRPGDAC/TAPMAC, was useful for predicting prognoses in patients with HF, and it showed an incremental prognostic value over RV systolic function.

Application of the proximal isovelocity surface area method for estimation of the effective orifice area in aortic stenosis.

Although the echocardiographic effective orifice area (EOA) calculated using the continuity equation is widely used for the assessment of severity in aortic stenosis (AS), the existence of high flow velocity at the left ventricular outflow tract (LVOT) potentially causes its overestimation. The proximal isovelocity surface area (PISA) method could be an alternative tool for the estimation of EOA that limits the influence of upstream flow velocity. EOA was calculated using the continuity equation (EOACont) and PISA method (EOAPISA), respectively, in 114 patients with at least moderate AS. The geometric orifice area (GOA) was also measured using the planimetry method in 51 patients who also underwent three-dimensional transesophageal echocardiography. Patients were divided into two groups according to the median LVOT flow velocity. EOAPISA could be obtained in 108 of the 114 patients (95%). Although there was a strong correlation between EOACont and EOAPISA (r = 0.78, P < 0.001), EOACont was statistically significantly larger than EOAPISA (0.86 ± 0.33 vs 0.75 ± 0.29 cm2, P < 0.001). Both EOACont and EOAPISA similarly correlated with GOA (r = 0.70, P < 0.001 and r = 0.77, P < 0.001, respectively). However, a fixed bias, which is hydrodynamically supposed to exist between EOA and GOA, was not observed between EOACont and GOA. In contrast, there was a negative fixed bias between EOAPISA and GOA with smaller EOAPISA than GOA. The difference between EOACont and GOA was significantly greater with a larger EOACont relative to GOA in patients with high LVOT flow velocity than in those without (0.16 ± 0.25 vs - 0.07 ± 0.10 cm2, P < 0.001). In contrast, the difference between EOAPISA and GOA was consistent regardless of the LVOT flow velocity (- 0.07 ± 0.12 vs - 0.07 ± 0.15 cm2, P = 0.936). The PISA method was applied to estimate EOA in patients with AS. EOAPISA could be an alternative parameter for AS severity grading in patients with high LVOT flow velocity in whom EOACont would potentially overestimate the orifice area.

Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction.

AIMS: Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF. METHODS AND RESULTS: We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan-Meier curves showed that VMT ≥2 (n = 54) was associated with worse outcomes than the VMT ≤1 group (n = 256) (P < 0.001). Furthermore, VMT ≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (AF) (P = 0.026). In the adjusted model, VMT ≥2 was independently associated with the primary outcome (hazard ratio 2.60, 95% confidence interval 1.46-4.61; P = 0.001). Additionally, VMT scoring provided an incremental prognostic value over clinically relevant variables and diastolic function grading (χ2 10.8-16.3, P = 0.035). CONCLUSIONS: In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF.

Influence of left ventricular systolic dysfunction on occurrence of pulsus tardus in patients with aortic stenosis.

BACKGROUND: Although the time difference between peak of left ventricular (LV) and aortic systolic pressures (TLV-Ao), which is considered to in part reflect pulsus tardus, is reported to be associated with clinical outcome in aortic stenosis (AS), its physiological determinants remain to be elucidated. We hypothesized that not only AS severity but also LV systolic dysfunction could be associated with occurrence of pulsus tardus. METHODS: TLV-Ao was measured by simultaneous LV and aortic pressure tracing in 74 AS patients and prolonged TLV-Ao was defined as ≥66 ms according to the previous report. Mean transaortic valvular pressure gradient (mPG) and effective orifice area index (EOAI) were estimated by Doppler echocardiography and severe AS was defined as EOAI ≤0.60 cm2/m2. Global longitudinal strain (GLS) was measured by using speckle-tracking method. RESULTS: Although a weak correlation was observed between EOAI and TLV-Ao, there was substantial population showing discordance between the parameters: severe AS despite normal TLV-Ao (10 of 47 patients) and moderate AS despite prolonged TLV-Ao (9 of 17 patients). In severe AS, mPG was significantly higher in patients showing prolonged TLV-Ao (57±20 vs 36±10 mmHg, p<0.0001) whereas GLS was comparable between the groups (-15.2±3.5% vs -14.8±3.2%). In contrast, in moderate AS, GLS was significantly smaller in patients showing prolonged TLV-Ao (-12.6±4.7% vs -17.4±3.4%, p=0.0271) while mPG was comparable (34±7 mmHg vs 35±8 mmHg). Multivariable analysis revealed that not only mPG but also GLS was an independent determinant of TLV-Ao. CONCLUSIONS: The occurrence of pulsus tardus could be associated with not only AS severity but also LV systolic dysfunction in AS patients.

Simple Two-Dimensional Echocardiographic Scoring System for the Estimation of Left Ventricular Filling Pressure.

BACKGROUND: When left ventricular filling pressure (LVFP) increases, the mitral valve opens early and precedes tricuspid valve opening in early diastole. The authors hypothesized that a visually assessed time sequence of atrioventricular valve opening could become a new marker of elevated LVFP. The aim of this study was to test the diagnostic ability of a novel echocardiographic scoring system, the visually assessed time difference between mitral valve and tricuspid valve opening (VMT) score, in patients with heart failure. METHODS: One hundred nineteen consecutive patients who underwent cardiac catheterization within 24 hours of echocardiographic examination were retrospectively analyzed as a derivation cohort. In addition, a prospective study was conducted to validate the diagnostic ability of the VMT score in 50 patients. Elevated LVFP was defined as mean pulmonary artery wedge pressure (PAWP) ≥ 15 mm Hg. The time sequence of atrioventricular valve opening was visually assessed and scored (0 = tricuspid valve first, 1 = simultaneous, 2 = mitral valve first). When the inferior vena cava was dilated, 1 point was added, and VMT score was ultimately graded as 0 to 3. Cardiac events were recorded for 1 year after echocardiography. RESULTS: In the derivation cohort, PAWP was elevated with higher VMT scores (score 0, 10 ± 5; score 1, 12 ± 4; score 2, 22 ± 8; score 3, 28 ± 4 mm Hg; P < .001, analysis of variance). VMT score ≥ 2 predicted elevated PAWP with accuracy of 86% and showed incremental predictive value over clinical variables and guideline-recommended diastolic function grading. These observations were confirmed in the prospective validation cohort. Importantly, VMT score ≥ 2 discriminated elevated PAWP with accuracy of 82% in 33 patients with monophasic left ventricular inflow in the derivation cohort. Kaplan-Meier analysis demonstrated that patients with VMT scores ≥ 2 were at higher risk for cardiac events than those with VMT scores ≤ 1 (P < .001). CONCLUSIONS: VMT scoring could be a novel additive marker of elevated LVFP and might also be associated with adverse outcomes in patients with heart failure.

Influence of advanced pulmonary vascular remodeling on accuracy of echocardiographic parameters of left ventricular filling pressure.

Evaluation of left ventricular filling pressure plays an important role in the clinical management of pulmonary hypertension. However, the accuracy of echocardiographic parameters for the determination of left ventricular filling pressure in the presence of pulmonary vascular lesions has not been fully addressed. We retrospectively investigated 124 patients with pulmonary hypertension due to pulmonary vascular lesions (noncardiac pulmonary hypertension group) and 113 patients with ischemic heart disease (control group) who underwent right heart catheterization and echocardiography. The noncardiac pulmonary hypertension group was subdivided into less-advanced and advanced groups according to median pulmonary vascular resistance. Pulmonary artery wedge pressure was determined as left ventricular filling pressure. As echocardiographic parameters of left ventricular filling pressure, the ratio of early- (E) to late-diastolic transmitral flow velocity (E/A), ratio of E to early-diastolic mitral annular velocity (E/e'), and left atrial volume index were measured. In the less-advanced noncardiac pulmonary hypertension and control groups, positive correlations were observed between pulmonary artery wedge pressure and late-diastolic transmitral flow velocity (R = 0.41, P = 0.002 and R = 0.71, P < 0.001, respectively) and left atrial volume index (R = 0.53, P < 0.001 and R = 0.41, P < 0.001), whereas in the advanced noncardiac pulmonary hypertension group, pulmonary artery wedge pressure was only correlated with left atrial volume index (R = 0.27, P = 0.032). In the controls, only pulmonary artery wedge pressure determined E (ß = 0.48, P < 0.001), whereas both pulmonary artery wedge pressure and pulmonary vascular resistance were independent determinants of E (ß = 0.29, P < 0.001 and ß = -0.28, P = 0.001, respectively) in the noncardiac pulmonary hypertension group. In conclusion, in the presence of advanced pulmonary vascular lesions, conventional echocardiographic parameters may not accurately reflect left ventricular filling pressure. Elevated pulmonary vascular resistance would lower the E, even when pulmonary artery wedge pressure is elevated, resulting in blunting of echocardiographic parameters for the detection of elevated left ventricular filling pressure.

Functional significance of intra-left ventricular vortices on energy efficiency in normal, dilated, and hypertrophied hearts.

PURPOSE: To investigate the influence of changes in vortices within the left ventricle (LV) on energy efficiency (EE) in normal and diseased hearts. METHODS: We performed vector flow mapping echocardiography in 36 normal participants (N), 36 patients with dilated cardiomyopathy (D), and 36 patients with LV hypertrophy (H). The circulation of the main anterior vortex was measured as a parameter of vortex strength. Energy loss (EL) was measured for one cardiac cycle, and EE was calculated as EL divided by stroke work (SW), which represents the loss of kinetic energy per unit of LV external work. RESULTS: Circulation increased in the order of N, H, and D (N: 15 ± 4, D: 19 ± 8, H: 17 ± 6 × 10-3 m2 /s; analysis of variance [ANOVA] P < .01). Conversely, EE increased in the order of N, D, and H (N: 0.22 ± 0.07, D: 0.26 ± 0.16, H: 0.30 ± 0.16 10-5 J/mm Hg mL m s; ANOVA P = .04), suggesting worst EE in group H. We found a positive correlation between circulation and SW only in group N, and positive correlation between circulation and EE only in diseased groups (D: R = 0.55, P < .01; H: R = 0.44, P < .01). Multivariable analyses revealed that circulation was the independent determinant of EE in groups D and H. CONCLUSIONS: Enhanced vortices could be associated with effective increase in LV external work in normal hearts. Conversely, they were associated with loss of EE without an optimal increase in external work in failing hearts, regardless of the LV morphology.

Significance and prognostic impact of v wave on pulmonary artery pressure in patients with heart failure: beyond the wedge pressure.

BACKGROUND: A v wave on pulmonary artery wedge (PAW) pressure sometimes augments and appears on pulmonary artery (PA) pressure wave in patients with heart failure (HF). However, the significance of PA v wave in HF remains to be elucidated. METHODS: We retrospectively analyzed pressure waveforms in 61 HF patients (left ventricular ejection fraction 35 ± 15%). On the PAW and PA pressure waveforms, mean pressure as well as peak and amplitude of v waves (ampPAWv and ampPAv, respectively) were measured. Occurrence of worsening HF and cardiac death was recorded for 2 years after the catheterization. RESULTS: The ampPAWv did not correlate with ampPAv. When the patients were divided into 4 groups: I (high-ampPAWv/high-ampPAv), II (high-ampPAWv/low-ampPAv), III (low-ampPAWv/high-ampPAv), and IV (low-ampPAWv/low-ampPAv), the prevalence of group III was low (I: 13, II: 17, III: 4, IV: 27). Mean pressures of PAW and PA were similarly elevated in groups I and II. Cardiac index was lowest (I: 2.0 ± 0.4, II: 2.8 ± 0.6, III: 2.2 ± 0.2, IV: 2.4 ± 0.6 L/min/m2, ANOVA P < 0.01, P < 0.01 for I vs II) and tricuspid annular plane systolic excursion / systolic PA pressure was impaired (I: 0.27 ± 0.07, II: 0.48 ± 0.22, III: 0.59 ± 0.35, IV: 0.68 ± 0.35 mm/mmHg, ANOVA P < 0.01) in group I. During the follow-up, 13 events were observed. Kaplan-Meier analysis showed that patients in group I were at highest risk of cardiac events. CONCLUSIONS: PA v was observed mainly in patients with augmented PAW v wave and decreased cardiac index, suggesting an advanced stage of HF. Moreover, augmented PAv was associated with worse outcome in HF patients.

Heart Failure With Preserved Ejection Fraction vs. Reduced Ejection Fraction　- Mechanisms of Ventilatory Inefficiency During Exercise in Heart Failure.

Background: Ventilatory inefficiency during exercise assessed using the lowest minute ventilation/carbon dioxide production (V̇E/V̇CO2) ratio was recently proven to be a strong prognostic marker of heart failure (HF) regardless of left ventricular ejection fraction (LVEF). Its physiological background, however, has not been elucidated. Methods and Results: Fifty-seven HF patients underwent cardiopulmonary exercise testing and exercise-stress echocardiography. The lowest V̇E/V̇CO2 ratio was assessed on respiratory gas analysis. Echocardiography was obtained at rest and at peak exercise. LVEF was measured using the method of disks. Cardiac output (CO) and the ratio of transmitral early filling velocity (E) to early diastolic tissue velocity (e') were calculated using the Doppler method. HF patients were divided into preserved EF (HFpEF) and reduced EF (HFrEF) using the LVEF cut-off 40% at rest. Twenty-four patients were classified as HFpEF and 33 as HFrEF. In HFpEF, age (r=0.58), CO (r=-0.44), e' (r=-0.48) and E/e' (r=0.45) during exercise correlated with the lowest V̇E/V̇CO2 ratio (P<0.05 for all). In contrast, in HFrEF, age (r=0.47) and CO (r=-0.54) during exercise, but not e' and E/e', correlated with the lowest V̇E/V̇CO2 ratio. Conclusions: Loss of CO augmentation was associated with ventilatory inefficiency in HF regardless of LVEF, although lung congestion determined ventilatory efficiency only in HFpEF.