Background—Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether mitral annular velocities as assessed by tissue Doppler imaging are associated with invasive measures of diastolic LV performance and whether additional information is gained over traditional Doppler variables. Methods and Results—One hundred consecutive patients referred for cardiac catheterization underwent simultaneous Doppler interrogation. Invasive measurements of LV pressures were obtained with micromanometer-tipped catheters, and the mean LV diastolic pressure (M-LVDP) was used as a surrogate for mean left atrial pressure. Doppler signals from the mitral inflow, pulmonary venous inflow, and TDI of the mitral annulus were obtained. Isolated parameters of transmitral flow correlated with M-LVDP only when ejection fraction <50%. The ratio of mitral velocity to early diastolic veloc...

Clinical Utility of Doppler Echocardiography and Tissue Doppler Imaging in the Estimation of Left Ventricular Filling Pressures A Comparative Simultaneous Doppler-Catheterization Study

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)03034-1.pdf

Biochemical detection of left-ventricular systolic dysfunction

Aims To prospectively compare the agreement of left ventricular volumes and ejection fraction by M-mode echocardiography (echo), 2D echo, radionuclide ventriculography and cardiovascular magnetic resonance performed in patients with chronic stable heart failure. It is important to know whether the results of each technique are interchangable, and thereby how the results of large studies in heart failure utilizing one technique can be applied using another. Some studies have compared cardiovascular magnetic resonance with echo or radionuclude ventriculography but few contain patients with heart failure and none have compared these techniques with the current fast breath-hold acquisition cardiovascular magnetic resonance.

Methods and Results Fifty two patients with chronic stable heart failure taking part in the CHRISTMAS Study, underwent M-mode echo, 2D echo, radionuclude ventriculography and cardiovascular magnetic resonance within 4 weeks. The scans were analysed independently in blinded fashion by a single investigator at three core laboratories. Of the echocardiograms, 86% had sufficient image quality to obtain left ventricular ejection fraction by M-mode method, but only 69% by 2D Simpson's biplane analysis. All 52 patients tolerated the radionuclude ventriculography and cardiovascular magnetic resonance, and all these scans were analysable. The mean left ventricular ejection fraction by M-mode cube method was 39±16% and 29±15% by Teichholz M-mode method. The mean left ventricular ejection fraction by 2D echo Simpson's biplane was 31±10%, by radionuclude ventriculography was 24±9% and by cardiovascular magnetic resonance was 30±11. All the mean left ventricular ejection fractions by each technique were significantly different from all other techniques ( P <0·001), except for cardiovascular magnetic resonance ejection fraction and 2D echo ejection fraction by Simpson's rule ( P =0·23). The Bland–Altman limits of agreement encompassing four standard deviations was widest for both cardiovascular magnetic resonance vs cube M-mode echo and cardiovascular magnetic resonance vs Teichholz M-mode echo at 66% each, and was 58% for radionuclude ventriculography vs cube M-mode echo, 44% for cardiovascular magnetic resonance vs Simpson's 2D echo, 39% for radionuclide ventriculography vs Simpson's 2D echo, and smallest at 31% for cardiovascular magnetic resonance–radionuclide ventriculography. Similarly, the end-diastolic volume and end-systolic volume by 2D echo and cardiovascular magnetic resonance revealed wide limits of agreement (52ml to 216ml and 11ml to 188ml, respectively).

Conclusion These results suggest that ejection fraction measurements by various techniques are not interchangeable. The conclusions and recommendations of research studies in heart failure should therefore be interpreted in the context of locally available techniques. In addition, there are very wide variances in volumes and ejection fraction between techniques, which are most marked in comparisons using echocardiography. This suggests that cardiovascular magnetic resonance is the preferred technique for volume and ejection fraction estimation in heart failure patients, because of its 3D approach for non-symmetric ventricles and superior image quality.

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Comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance. Are they interchangeable?

Background— Although Doppler echocardiography has been used to identify abnormal left ventricular (LV) diastolic filling dynamics, inherent limitations suggest the need for additional measures of diastolic dysfunction. Because data suggest that B-natriuretic peptide (BNP) partially reflects ventricular pressure, we hypothesized that BNP levels could predict diastolic abnormalities in patients with normal systolic function. Methods and Results— We studied 294 patients referred for echocardiography to evaluate ventricular function. Patients with abnormal systolic function were excluded. Cardiologists making the assessment of LV function were blinded to BNP levels. Patients were classified as normal, impaired relaxation, pseudonormal, and restrictivelike filling patterns. Patients diagnosed with evidence of abnormal LV diastolic function (n=119) had a mean BNP concentration of 286±31 pg/mL; those in the normal LV group (n=175) had a mean BNP concentration of 33±3 pg/mL. Patients with restrictivelike filling ...

Utility of B-Natriuretic Peptide in Detecting Diastolic Dysfunction Comparison With Doppler Velocity Recordings

A simple, reproducible, noninvasive Doppler index for the assessment of overall cardiac function has been described previously. The purpose of this study was to correlate the Doppler index with accepted indexes of cardiac catheterization of left ventricular performance. Thirty-four patients with ischemic heart disease or idiopathic dilated cardiomyopathy prospectively underwent a simultaneous cardiac catheterization and Doppler echocardiographic study. Invasive measurements of peak +dP/dt, peak -dP/dt, and tau were obtained from the high-fidelity left ventricular pressures. A Doppler index of myocardial performance was defined as the summation of isovolumetric contraction and relaxation time divided by ejection time. There was a correlation between Doppler measurement of isovolumetric contraction time and peak +dP/dt (r = 0.842; p < 0.0001) and Doppler measurement of isovolumetric relaxation time and peak -dP/dt (r = 0.638; p < 0.001). Left ventricular ejection time correlated with both peak +dP/dt (r = 0.539; p < 0.001) and peak -dP/dt (r = 0.582; p < 0.001). The Doppler index correlated with simultaneously recorded systolic peak +dP/dt (r = 0.821; p < 0.0001) and diastolic peak -dP/dt (r = 0.833; p < 0.001) and tau (r = 0.680; p < 0.0001). This study documents that a simple, easily recordable, noninvasive Doppler index of myocardial performance correlates with invasive measurement of left ventricular systolic and diastolic function and appears to be a promising noninvasive measurement of overall cardiac function.

Noninvasive Doppler-derived myocardial performance index: Correlation with simultaneous measurements of cardiac catheterization measurements

To evaluate the applicability of two-dimensional echocardiography to left ventricular volume determination, 30 consecutive patients undergoing biplane left ventricular cineangiography were studied with a wide-angle (84 degrees), phased-array, two-dimensional echocardiographic system. Two echographic projections were used to obtain paired, biplane, tomographic images of the left ventricle. We used the short-axis view (from the precordial window) as an anolog of the left anterior oblique angiogram, and the long-axis, two-chamber view (from the apex impulse window) as a right anterior oblique angiographic equivalent. A modified Simpson's rule formula was used to calculate systolic and diastolic left ventricular volumes from the biplane echogram and the biplane angiogram. These methods correlated well for ejection fraction (r = 0.87) and systolic volume (r = 0.90), but only modestly for diastolic volume (r = 0.80). These correlations are noteworthy because 65% of the patients had significant segmental wall motion abnormalities. The volumes determined from the minor-axis dimensions of M-mode echograms in 23 of the same patients correlated poorly with angiography.

Left ventricular volume from paired biplane two-dimensional echocardiography.

A patient with severe, chronic congestive heart failure was unresponsive not only to conventional therapy, but also to nonparenteral nitroglycerin and isosorbide dinitrate; he became nitro...

Combination Vasodilator Therapy for Severe Chronic Congestive Heart Failure

Gated radionuclide angiography (RVG) in orthogonal projections was used to evaluate left ventricular volume, ejection fraction, and segmental wall motion. Images of the left ventricle at end-diastole and end-systole were outlined in two projections using a simple manual method. The perimeter drawings were digitized on a desktop computer, interfaced to an XY recorder and left ventricular volumes and ejection fraction calculated. The results were compared to contrast left ventriculography (CVG) in the same projections. RVG and CVG gave similar results for end-diastolic volume (r = .87, P less than 0.001), end-systolic volume (r = .95, P less than 0.001), and ejection fraction (r = .89, P less than 0.001) over a wide range of values. In 92% of all left ventricular segments analyzed, RVG and CVG showed only minor differences in the analysis of wall motion. Reproducibility of the method by a trained observer was excellent. Interobserver trials demonstrated that less well-trained observers consistently over- or underestimated volumes, emphasizing the need for prior experience in RVG analysis. Use of this manual method for analysis of gated equilibrium RVG in orthogonal projections appears to be a reasonably accurate, reproducible method for evaluating left ventricular function.

Denis Drew

Papers

Left ventricular volume from paired biplane two-dimensional echocardiography.

Combination Vasodilator Therapy for Severe Chronic Congestive Heart Failure

Evaluation of left ventricular performance by gated radionuclide angiography.