Impact of Adrenalectomy on Diastolic Cardiac Dysfunction in Patients with Primary Aldosteronism.

Poor prognostic cardiac function is known among some patients with primary aldosteronism (PA). However, studies with echocardiograms on whether the normalization of aldosterone after laparoscopic adrenalectomy (LADX) improves myocardial hypertrophy and diastolic cardiac dysfunction have been inadequate. Between August 2009 and December 2021, 147 patients with unilateral PA who underwent pre- and post-LADX echocardiography at a single center were enrolled in this retrospective study. We evaluated the cardiac impact of LADX by comparing patients who demonstrated complete clinical success (CS) with those who demonstrated partial or absent CS. Adjusted odds ratios (ORs) for not obtaining complete CS were calculated using binomial logistic regression analysis for clinically significant items among the pre- and postoperative clinical and echocardiographic markers. Overall, 47 (29%) and 104 (71%) patients had complete and partial or absent CS, respectively. Compared to patients with complete CS, patients with partial CS or without CS tended to have preoperative low early to late diastolic transmitral flow velocity (E/A) (< 0.8 cm/s) (41% vs. 21%, P < 0.05) and postoperative supranormal left ventricular ejection fraction (LVEF) (> 70%) (37% vs. 21%, P < 0.05). Furthermore, laparoscopic adrenalectomy improved the low and high echocardiographic values of E/A and LVEF, respectively, in both groups. The risk factors for not reaching complete CS were male sex (OR 3.42), low preoperative E/A (OR 3.11), and postoperative supranormal LVEF (OR 3.17). Although low preoperative E/A and postoperative supranormal LVEF are associated with poor clinical outcomes, LADX can improve diastolic cardiac function in patients with PA.

Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation.

Background: Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF). Objectives: This study aimed to investigate the prognostic value of echocardiographic markers of congestion that can be applied to both AF and patients without AF with HFpEF. Methods: We conducted a multicenter study of 505 patients with HFpEF admitted to hospitals for acute decompensated heart failure. The ratio of early diastolic transmitral flow velocity to mitral annulus velocity (E/e'), the tricuspid regurgitation peak velocity, and the collapsibility of the inferior vena cava were obtained at discharge. Congestion was determined by echocardiography if any one of E/e' ≥14 (E/e' ≥11 for AF), tricuspid regurgitation peak velocity ≥2.8 m/s, or inferior vena cava collapsibility <50% was positive. We classified patients into grade A, grade B, and grade C according to the number of positive congestion indices. The primary endpoint was the composite of cardiovascular death and heart failure hospitalization. Results: During the follow-up period (median: 373 days), 162 (32%) patients experienced the primary endpoint. Grade C patients had a higher risk for the primary endpoint than grade A (HR: 2.98; 95% CI: 1.97-4.52) and grade B patients (HR: 1.92; 95% CI: 1.29-2.86) (log-rank P < 0.0001). Echocardiographic congestion grade improved the predictive value when added to the age, sex, New York Heart Association functional class, and N-terminal pro-B-type natriuretic peptide, not only in sinus rhythm (Uno C-statistic: 0.670 vs 0.655) but in AF (Uno C-statistic: 0.667 vs 0.639). Conclusions: Echocardiographic congestion grade has prognostic value in patients with HFpEF with and without AF.

Safety and Tolerability of Nicotinamide Riboside in Heart Failure With Reduced Ejection Fraction.

The mitochondrial dysfunction characteristic of heart failure (HF) is associated with changes in intracellular nicotinamide adenine dinucleotide (NAD+) and NADH levels. Raising NAD+ levels with the NAD+ precursor, nicotinamide riboside (NR), may represent a novel HF treatment. In this 30-participant trial of patients with clinically stable HF with reduced ejection fraction, NR, at a dose of 1,000 mg twice daily, appeared to be safe and well tolerated, and approximately doubled whole blood NAD+ levels. Intraindividual NAD+ increases in response to NR correlated with increases in peripheral blood mononuclear cell basal (R 2 = 0.413, P = 0.003) and maximal (R 2 = 0.434, P = 0.002) respiration, and with decreased NLRP3 expression (R 2 = 0.330, P = 0.020). (Nicotinamide Riboside in Systolic Heart Failure; NCT03423342).

Clinical Utility of Overlap Time for Incomplete Relaxation to Predict Cardiac Events in Heart Failure.

BACKGROUND: The overlap time of transmitral flow can be a novel marker of subclinical left ventricular dysfunction for predicting adverse events in heart failure (HF). We aimed to (1) investigate the role of overlap time of the E-A wave in association with clinical parameters and (2) evaluate whether the overlap time could add prognostic information with respect to other conventional clinical prognosticators in HF. METHODS: We prospectively evaluated 153 patients hospitalized with HF (mean age 68 ± 15 years; 63% male). The primary endpoint was readmission following HF or cardiac death. RESULTS: During a median period of 25 months, 43 patients were readmitted or died. Overlap time appeared to be associated with worse outcomes. After adjustment for readmission scores and ratios of diastolic filling period and cardiac cycle length in a Cox proportional-hazards model, overlap time was associated with event-free survival, independent of elevated left atrial pressure based on guidelines. When overlap time was added to the model based on clinical variables and elevated left atrial pressure, the C-statistic significantly improved from 0.70 (95% CI: 0.63-0.77) to 0.77 (95% CI: 0.69-0.83, compared) (P = 0.035). CONCLUSION: This preliminary study suggested that prolonged overlap time may have potential for predicting readmission and cardiac mortality risk assessment in patients with HF.

Transient atrial mechanical dysfunction assessed in acute phase of embolic stroke of undetermined source.

BACKGROUND AND PURPOSE: Paroxysmal atrial fibrillation (PAF) has been suggested as a major cause of embolic stroke of undetermined source (ESUS). Transient atrial mechanical dysfunction (stunning) frequently occurs after conversion of atrial fibrillation to sinus rhythm. The study aim was to determine if reversible atrial mechanical dysfunction in ESUS could help elucidate the mechanism of stroke. METHODS: Eighty-five consecutive patients with acute ischemic stroke were enrolled according to the following inclusion criteria: [1] ≥55 years old; [2] normal sinus rhythm upon admission; [3] no apparent embolic source; and [4] transthoracic echocardiographic evaluation had been performed in both the early phase (<72 h) and late phase (>7 days) after stroke onset. There were 27 patients in the lacunar or atherothrombotic infarction group (controls), 22 in the PAF group, and 36 in the ESUS group. To determine atrial stunning, transmitral flow velocity profiles (Doppler peak E- [early diastolic] and A- [atrial systolic] waves) were obtained. RESULTS: In the early phase, an E/A velocity ratio ≥ 1.0 was less common in the control group (1 patient, 3.7%) than in the PAF group (19 patients, 86.4%; p < 0.001) and ESUS group (10 patients, 27.8%; p < 0.05). In the late phase, the E/A ratio decreased to less than 1.0 in six patients (31.6%) who had PAF and in eight patients (80.0%) who had ESUS. CONCLUSION: Transient atrial mechanical dysfunction could be a helpful finding for elucidating the stroke mechanism in patients with ESUS, and early echocardiographic assessment could improve its detection.

Renal Resistive Index of the Main Renal Arteries and Transmitral Flow in Hypertensive Patients.

In hypertensive patients, diastolic dysfunction is related to increased resistive index (RI) of parenchymal renal arteries. To determine the existence of a link between RI of the main renal arteries (RRI) and diastolic dysfunction, a group of 127 hypertensive patients, with glomerular filtration rates >50 mL/min (mean estimated glomerular filtration rate: 88.6 ± 15.2 mL/min) and no comorbidities, was studied. RRI and transmitral flow were evaluated using the deceleration time (DT) and E/A ratio. A statistically significant correlation between RRI and DT (>240 ms) was noted (p < 0.001). The RRI cutoff that best discriminated patients with DT >240 ms was 0.675. For each unitary increment of 10 mm in DT, the log-transformed RRI significantly increased by a mean of 0.006 point (p < 0.001). This study revealed the importance of the link between RRI and transmitral DT in addition to the renowned significance of the increase in RI as a cardiovascular risk factor in hypertensive patients without comorbidities.

Clinical Application of Stress Echocardiography in Management of Heart Failure.

The key to understanding hemodynamics in heart failure (HF) is the relation between elevated left ventricular (LV) filling pressure and cardiac output. Some patients show abnormal response to stress in the relationship between LV filling pressure and cardiac output. In patients with preserved diastolic function, cardiac output can be increased without significantly elevated filling pressure during stress. In patients with HF, as long as the Frank-Starling mechanism operates effectively, cardiac output can increase while acquiring elevated filling pressure. In patients with decompensated HF, hemodynamic stress will lead to a much greater elevation in filling pressure and pulmonary venous hypertension.

Maniobra de handgrip y patrón pseudonormal del flujo transmitral en pacientes jóvenes con corazón estructuralmente sano / Handgrip maneuver and pseudonormal transmitral flux pattern in young patients with a structurally healthy heart

El flujo transmitral, a pesar de que su sóla modificación ya no representa un criterio para definir disfunción diastólica, sigue siendo el primer paso para el diagnóstico. El patrón pseudonormal sigue siendo un reto en cuanto a su diferenciación con el patrón normal o anormal en la población, sin embargo resulta interesante conocer la prevalencia de este patrón en poblaciones jóvenes con corazón estructuralmente sano. Para ello, se realizó un estudio descriptivo transversal en 38 pacientes jóvenes con corazón estructuralmente sano, sin enfermedades cardiovasculares previamente diagnosticadas, que acudieron al Centro Cardiovascular Regional ASCARDIO en el período enero-marzo 2019. Se practicó un ecocardiograma transtorácico donde se realizaron determinaciones basales del flujo transmitral y posterior a la aplicación de la maniobra de Handgrip. Los resultados demuestran que el 68% de los pacientes mostraron patrón pseudonormal del flujo transmitral. Al momento de realizar la maniobra de Handgrip, el 84% de los individuos mostraron un patrón de flujo normal mientras el 6% correspondieron a patrón pseudonormal siendo la distribución por sexo equitativa para cada categoría. La maniobra de Handgrip resulta útil para desenmascarar el patrón pseudornomal a normal del flujo transmitral y en sentido contrario, en pacientes con corazón estructuralmente sano(AU)

Transmitral flow, although its single modification no longer represents a criteria to define diastolic dysfunction, remains the first step for diagnosis. The pseudonormal pattern remains a challenge in terms of its differentiation with the normal or abnormal pattern in the population, however it is interesting to know the prevalence of this pattern in young populations with structurally healthy heart. We performed a descriptive transversal study in 38 patients with a structurally healthy heart and no known cardiovascular disease, who attended the Regional Cardiovascular Center ASCARDIO in the period January-March 2019. A transthoracic echocardiogram was performed where baseline determinations of transmitral flow and subsequent to the application of the Handgrip maneuver were made. The results show that 68% of patients had a pseudonormal pattern of transmitral flow. After performing the Handgrip maneuver, 84% of the individuals showed a normal flow pattern while 6% had a pseudonormal pattern, with an equal distribution by sex. Handgrip maneuver is useful to unmask the pseudonormal to normal pattern of transmitral flow and in the opposite direction, in patients with structurally healthy heart(AU)

The ratio of early transmitral flow velocity (E) to early mitral annular velocity (Em) predicts improvement in left ventricular systolic and diastolic function 1 year after catheter ablation for atrial fibrillation.

AIMS: Successful rhythm control after atrial fibrillation catheter ablation is known to induce left atrial reverse remodelling and improve left ventricular (LV) function. We explored the clinical factors affecting LV systolic and diastolic function 1-year after catheter ablation for atrial fibrillation. METHODS AND RESULTS: We compared pre-procedural and 1-year follow-up echocardiograms in 521 patients with atrial fibrillation who underwent catheter ablation. Left ventricular systolic function was estimated by the ejection fraction (EF); diastolic function was estimated by the ratio of early transmitral flow velocity (E) to early mitral annular velocity (Em). (i) Catheter ablation of atrial fibrillation significantly reduced left atrium volume index (P < 0.001) and improved LV EF both in patients with recurrent atrial fibrillation (n = 133, P = 0.008) and those without recurrence (n = 388, P < 0.001). (ii) Follow-up EF was significantly improved in patients with baseline E/Em < 15 (n = 454, P < 0.001), whereas E/Em was significantly reduced in patients with pre-procedural E/Em ≥ 15 (n = 67, P = 0.008). (iii) Baseline E/Em < 15 (ß = -3.854, 95% CI -5.99 to -1.72, P < 0.001), baseline EF <50% (ß = 10.586, 95% CI 7.55 to 13.63, P < 0.001), and female (ß = -1.726, 95% CI -3.36 to -0.10, P = 0.038) were independently associated with improved EF. Baseline E/Em ≥ 15 (ß = 4.896, 95% CI 3.45 to 6.34, P < 0.001) and younger age (ß = -0.066, 95% CI -0.11 to -0.02, P = 0.003) were independent factors associated with improved E/Em. CONCLUSION: Pre-procedural E/Em predicted improvement in LV systolic and diastolic functions 1 year after catheter ablation for atrial fibrillation. Low baseline E/Em was independently associated with improved EF, while high E/Em predicted improvement in LV diastolic function.

Ventricular septal dysfunction after surgical closure of multiple ventricular septal defects.

BACKGROUND: We assessed the global and regional ventricular septal functions using conventional echocardiography and two-dimensional speckle tracking imaging in children with postoperative multiple ventricular septal defects. METHODS: Thirty-six children were studied: 16 with postoperative multiple ventricular septal defects and 20 normal control subjects. In children with multiple ventricular septal defects, 60 ventricular septal defects were closed using one of three different techniques (patch closure, the sandwich technique, direct closure). Speckle tracking imaging was applied to three short-axis echocardiographic images. RESULTS: The total patch area used in the multiple ventricular septal defects group was correlated with the postoperative ejection fraction (r=0.703) and Tei index (r=0.778). The global septal peak systolic radial displacement and global septal peak systolic radial strain in the multiple ventricular septal defects group were significantly lower than those observed in the control subjects. The peak systolic radial strain in the segments closed with patches and the peak systolic radial displacement in the segments closed with the felt sandwich technique were significantly lower than those observed in the intact septal segments. No significant regional functional depressions were identified in the segments that were closed directly. CONCLUSIONS: The postoperative ventricular global and septal functions were significantly reduced in children with multiple ventricular septal defects, especially in the cases with complex congenital heart disease and that were closed with large prosthetic materials. These results suggest that an effort to minimize the use of patch materials may lead to preserved postoperative ventricular function.

Chagas disease: an overview of clinical and epidemiological aspects.

Chagas disease, caused by the parasite Trypanosoma cruzi, is a serious health problem in Latin America and is an emerging disease in non-endemic countries. In recent decades, the epidemiological profile of the disease has changed due to new patterns of immigration and successful control in its transmission, leading to the urbanization and globalization of the disease. Dilated cardiomyopathy is the most important and severe manifestation of human chronic Chagas disease and is characterized by heart failure, ventricular arrhythmias, heart blocks, thromboembolic phenomena, and sudden death. This article will present an overview of the clinical and epidemiological aspects of Chagas disease. It will focus on several clinical aspects of the disease, such as chronic Chagas disease without detectable cardiac pathology, as well as dysautonomia, some specific features, and the principles of treatment of chronic cardiomyopathy.

The vortex formation time to diastolic function relation: assessment of pseudonormalized versus normal filling.

In early diastole, the suction pump feature of the left ventricle opens the mitral valve and aspirates atrial blood. The ventricle fills via a blunt profiled cylindrical jet of blood that forms an asymmetric toroidal vortex ring inside the ventricle whose growth has been quantified by the standard (dimensionless) expression for vortex formation time, VFTstandard = {transmitral velocity time integral}/{mitral orifice diameter}. It can differentiate between hearts having distinguishable early transmitral (Doppler E-wave) filling patterns. An alternative validated expression, VFTkinematic reexpresses VFTstandard by incorporating left heart, near "constant-volume pump" physiology thereby revealing VFTkinematic's explicit dependence on maximum rate of longitudinal chamber expansion (E'). In this work, we show that VFTkinematic can differentiate between hearts having indistinguishable E-wave patterns, such as pseudonormal (PN; 0.75 < E/A < 1.5 and E/E' > 8) versus normal. Thirteen age-matched normal and 12 PN data sets (738 total cardiac cycles), all having normal LVEF, were selected from our Cardiovascular Biophysics Laboratory database. Doppler E-, lateral annular E'-waves, and M-mode data (mitral leaflet separation, chamber dimension) was used to compute VFTstandard and VFTkinematic. VFTstandard did not differentiate between groups (normal [3.58 ± 1.06] vs. PN [4.18 ± 0.79], P = 0.13). In comparison, VFTkinematic for normal (3.15 ± 1.28) versus PN (4.75 ± 1.35) yielded P = 0.006. Hence, the applicability of VFTkinematic for diastolic function quantitation has been broadened to include analysis of PN filling patterns in age-matched groups.

A case of mitochondrial cardiomyopathy with restrictive transmitral filling pattern.

A 61-year-old diabetic woman with a mitochondrial A3243G mutation was hospitalized for evaluation of breathlessness, general fatigue, and leg edema. Chest radiography revealed cardiomegaly with massive pleural effusion. Serum lactate, pyruvate, and brain natriuretic peptide concentrations were elevated. Transthoracic echocardiography revealed a restrictive pattern of transmitral flow, although systolic function of the left ventricle was only mildly impaired. Based on these findings and her clinical course, the patient was diagnosed with right-sided heart failure caused by mitochondrial cardiomyopathy associated with a restrictive transmitral filling pattern. Treatment with furosemide, enalapril, and eplerenone was effective, and improvement in her symptoms was associated with amelioration of transthoracic echocardiographic findings and a reduction in serum brain natriuretic peptide levels. Previous reports have indicated heterogeneity in the clinical features of mitochondrial cardiomyopathy in patients carrying the A3243G mutation; the present case highlights the substantial variability in the clinical features of this disease.

Doppler echocardiography in diastology: 35 years of Japanese contribution to its advancement and utility.

Echocardiography is one of the most important and clinically useful techniques in the assessment of diastolic function. Because of the prevalence of this technique, "diastology" and even the concept of diastolic heart failure have become familiar to researchers and physicians. We believe the first description by Kitabatake and his colleagues in 1982 of the use of Doppler technique to assess the transmitral flow velocity pattern in various cardiac diseases was the beginning of this development. Since then, a number of excellent works regarding echocardiographic assessment of diastolic function have emerged from Japan. Here, we review the Japanese contributions to the development of the use of Doppler echocardiography in diastology.

Aging and transmitral flow pattern in patients with systemic hypertension.

PURPOSE: Currently, the transmitral flow (TMF) pattern is routinely recorded as the first step in the assessment of left ventricular diastolic function. In young, healthy subjects, it is known that the early diastolic flow (E wave) of TMF is larger than the late diastolic flow (A wave). The E/A ratio then gradually decreases with age. This change in the pattern of TMF can be expected to occur earlier in patients with systemic hypertension than in healthy subjects. However, data pertaining to this matter are limited for Japanese patients. The purpose of this study was to investigate the changing pattern of TMF with age in Japanese patients with systemic hypertension. METHODS: A database of echocardiographic examination reports was surveyed. A total of 553 patients with systemic hypertension (HT group) and 394 patients without hypertension or organic heart disease (control group) were included in this study. The patients were subdivided according to age, after which the E/A ratio was compared for different patient categories and age groups. RESULTS: The E/A ratio gradually decreased with age in the control group, and the mean value of E/A was <1 in the sixth decade. On the other hand, the E/A ratio rapidly decreased and was <1 in the fifth decade in the HT group. CONCLUSION: In patients in the HT group, the E/A ratio decreased about a decade earlier compared with patients in the control group.

Dynamics of Left Ventricular Diastolic Filling during Progressive Exercise / 中国运动医学杂志

This study was to assess diastolic filling dynamics of the left ventricle during progressive upright cycle exercise in young men. The results showed that the diastolic filling period shortened from 0.581?0.14s at rest to 0.129?0.04s at peak exercise; the peak transmitral flow velocities increased from 0.72?0.07m/s at rest to 1.60?0.10m/s at peak exercise and the mean transmitral flow velocities increased from 0.41?0 03m/s at rest to 0.96?0.13m/s at peak exercise; the peak and mean transmitral pressure gradients rose fivefold from rest to peak exercise; the mitral flow volume per beat rose by 38% at 100W workloads and then remained stable. Conclusions Increases in transmitral pressure gradients with exercise may serve principally to augment the velocity of ventricular filling with the progressively shortening diastolic time period.

The Relationship between the Excursion of Mitral Valve Leaflets Recorded by M-Mode Echocardiography and the Transmitral Inflow Measured by Doppler Echocanliography

BACKGROUND AND OBJECTIVES: Movement of mitral valve during diastole and blood flow velocity through the valve can be accurately measured using M-mode and pulsed wave Doppler technique, respectively. However, the relationship between mechanical excursion and flow phenomenon at the same cardiac cycle has not been seriously investigated. METHOD: The subjects of this study included twenty cases with normal mitral flow pattern in Doppler echocardiography (Group I, mean age:44+/-20.8years, mean ejection fraction (EF):52+/-20.9%), twenty three cases with relaxation abnormality (Group II, mean age:59+/-11.4years, mean EF:43+/-18.2%) and seventeen cases with restrictive physiology (Group III, mean age: 47+/-15.9years, mean EF: 24+/-11.0%). We measured excursion of mitral leaflets at early (DE) and late (DA) diastole, area of mitral valvular opening using two dimensional calibration on M mode images, and transmitral inflow velocity (E (early ventricular filling)-, A (atrial contraction)-velocity), TVI (time velocity integral) on Doppler echocardiography. RESULTS: DE-excursions (mm) in group I, II, III were 16.8+/-4.7, 14.2+/-3.5, 15.3+/-4.1, DA-excursions (mm) were 9.8+/-3.2, 10.7+/-3.0, 8.3+/-2.7, E-areas (cm2) were 2.8+/-1.3, 2.6+/-0.8, 2.5+/-1.0, A-areas (cm2) were 1.7+/-0.8, 1.7+/-0.7, 2.0+/-0.6, respectively. In E-, A-velocity, deceleration time, E-TVI and A-TVI, there were significant differences among three groups. However, in DE-, DA-excursion, E-, A-area, there were no significant differences among three groups. Between DE excursion and E velocity, DA excursion and A velocity, and total opening area and total TVI in total subjects, significant correlations were absent. CONCLUSION: The mitral excursions and mitral opening areas on M mode images did not show any significant correlations with the mitral inflow velocities and TVI by pulsed Doppler, which suggests that the excursion of mitral leaflets is independent of transmitral inflow.

Thoracic epidural blockade preserves left ventricular early diastolic filling assessed by transesophageal echocardiography.

PURPOSE: The objective of this study was to examine the effect of thoracic epidural anesthesia (TEA) on left ventricular systolic and diastolic function assessed by transesophageal echocardiography under general anesthesia. METHODS: Sixteen patients were allocated to control (n=8) and TEA (n=8) groups. We administered 1% mepivacaine (8.9±1.2 ml) into the thoracic epidural space in the TEA group. RESULTS: The concomitant decline of the left vertricular systolic functional parameters, such as end-systolic diameter and fractional shortening, was observed, whereas preload, as measured by end-diastolic diameter, and afterload, as measured by end-systolic wall stress, were unchanged. No significant alteration was observed in early peak velocity or deceleration rate. The deceleration time was independent of heart rate and was unchanged. CONCLUSION: High TEA reduces fractional shortening without any changes in preload and afterload, indicating impairment of systolic function, but early peak velocity, deceleration rate, and deceleration time, which are the indices of diastolic function, are not changed during high TEA combined with general anesthesia.

Clinical Status in Patients Who Restrictive Pattern on Doppler Transmitral Flow Pattern

BACKGROUND: Restrictive pattern on Doppler transmitral flow pattern represent reduced left ventricular compliance and associated with poor prognosis in patients with systolic dysfunction due to congestive heart failure or myocaridal infarction. Although there are many clinical evaluation about clinical significance of restrictive transmitral flow pattern, investigation about what kinds of disease reveal the characteristic restrictive transmitral flow pattern and significance according to criteria of restrictive transmitral flow pattern is few. Therefore, we have analyzed patients with restrictive transmitral flow pattern in order to evaluate clinical diagnosis and clinical significance according to criteria of restrictive transmitral flow pattern. METHODS: The study population consisted of 229 patients(male 129 patients, female 102 patients, mean age 40.6 years old) who show E/A ratio p 2 on Doppler echocardiography from september 1994 to aprial 1996. We have reviewed the medical records of that patients. RESULTS: 1) In case of patients more than 2 at E/A ratio, we found that subjects not related with cardiovascular diseases were 76 persons(33.2%), valvular heart disease 75 patients(32.3%), ischemic heart disease 25 patients(10.9%), cardiomyopathy 16 patients(6.9%). Among valvular heart disease, mitral regurgitation was most frequently observed(44.5%). In these patients, patients with left ventricular systolic dysfunction were 60 patients(26.2%). 2) Patients more than 2 at E/A ratio and less than 150msec at deceleration time of E wave were 126 patients(55.0%). In these patients, we found that valvular heart disease was also most frequently observed(49 patients, 38.8%), subjects not related with cardiovascular diseases 30 persons(23.8%), cardiomyopathy 15 patients(11.9%),pericarditis 7 patients(5.6%), hypertension 3 patients(2-3%). Patients with left ventricular systolic dysfunction in this group were 39 patients(31.0%). CONCLUSION: Although restrictive transmitral flow pattern on Doppler echocardiography represents reduced compliance of left ventricle or severe heart failure in patients with symptoms of congestive heart failure, this pattern also may be seen in persons not related with cardiovascular disease. Therefore, when making dicision about clinical significance of restrictive pattern, one should consider about any factors can influece the transmitral flow pattern and correlate the clinical diagnosis with mitral flow velocity.