Gong-Yuan Xie

Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure

OBJECTIVES This study was designed to determine whether Doppler echocardiographic transmitral flow patterns can predict cardiac mortality in patients with congestive heart failure. BACKGROUND Previous studies have indicated that Doppler transmitral flow patterns are related to New York Heart Association functional class and exercise capacity in patients with congestive heart failure. However, the prognostic significance of these flow patterns is not known. METHODS We analyzed the relation of transmitral flow patterns and cardiac mortality in 100 consecutive patients (76 men, 24 women; mean [+/- SD] age 60 +/- 11 years) with congestive heart failure symptoms and left ventricular ejection fraction < 40%. At the time of entry into the study, functional class and ejection fraction by radionuclide angiography were determined, and Doppler echocardiography was performed in all patients. Transmitral flow was obtained from the apical four-chamber view at the mitral annulus level. Measurements included early (E) and atrial (A) filling velocities, E/A ratio and deceleration time of the E wave. The patients were assigned to two groups according to E/A ratio or deceleration time of transmitral flow patterns, or both: a non-restrictive group (42 patients) with E/A < or = 1 or E/A = 1 to 2 and deceleration time > 140 ms, and a restrictive group (58 patients) with E/A > or = 2 or E/A = 1 to 2 and deceleration time < or = 140 ms. RESULTS Of 100 patients, 26 died during a mean follow-up period of 16 +/- 8 months. The cumulative cardiac mortality rate determined by the Kaplan-Meier method was 14% at 1 year and 35% at 2 years. Cox proportional hazards model analysis revealed that transmitral flow (restrictive vs. nonrestrictive, chi-square 6.99, p = 0.008), patient gender (female vs. male, chi-square 4.59, p = 0.03) and New York Heart Association functional class (IV vs. II, chi-square 3.95, p = 0.05) were significantly related to cardiac mortality in patients with congestive heart failure. Mortality rate in the restrictive group was markedly higher than that in the nonrestrictive group at 1 year (19% vs. 5%, respectively, p < 0.05) and at 2 years (51% vs. 5%, respectively, p < 0.01) by log-rank test. Relative risk for cardiac death was estimated as 4.1 at 1 year and 8.6 at 2 years in the restrictive group compared with the nonrestrictive group. CONCLUSIONS In patients with congestive heart failure, a restrictive transmitral flow pattern, female gender and advanced functional class are predictive of higher cardiac mortality. The restrictive transmitral flow pattern by Doppler echocardiography is the single best clinical predictor for cardiac death in patients with congestive heart failure.

Musculoskeletal pain in cardiac ultrasonographers: results of a random survey

Myalgias and arthralgias are common among workers whose jobs require repetitive isometric maneuvers or malalignment of body position. However, few systematic studies have been performed to evaluate the frequency of these complaints among cardiac ultrasonographers. Therefore the purpose of this study was to determine the prevalence of musculoskeletal pain (MSP) among ultrasonographers and to identify risk factors related to their occurrence. Two hundred twenty ultrasonographers randomly chosen from a list of more than 1600 active members of the American Society of Echocardiography were mailed surveys consisting of 22 questions. Included were questions regarding height, age, years of experience, frequency and type of physical exercise, and job-related parameters such as a number of scans per day, scanning from right or left side of bed, number of hours, bed type, type of equipment, and manual or self-propelled machines. Respondents were asked whether they had had back, neck, or shoulder pain related to their profession and to describe treatment rendered and its effectiveness. One hundred thirteen (51%) of 220 ultrasonographers responded to the survey. Ninety (80%) of 113 respondents reported new pain that was not present before they began scanning, with 42 of this group (46%) requiring either physiotherapy (n = 17) or medication (n = 23). Treatment was believed to be helpful in 63% of cases. Factors found to have a positive relationship to MSP included ultrasonographer height less than 63 inches, performing 100 or more scans per month, average scan time of 25 minutes or more per patient, and use of manually propelled machines (each p < 0.05). Factors found to have no relationship to MSP included age, type of equipment, right or left scan position, physical conditioning, bed type, and time between patients. Musculoskeletal pain is prevalent among cardiac ultrasonographers, and may have specific work-related factors for its occurrence.

Reduction of left ventricular preload by lower body negative pressure alters Doppler transmitral filling patterns

The objective of this study was to evaluate the effect of alterations in preload induced by lower body negative pressure on Doppler transmitral filling patterns. Echocardiograms and Doppler recordings were performed in 18 normal young men (aged 23 to 32 years) during various levels of lower body negative pressure (0, -20 and -50 mm Hg). Lower body negative pressure induced a reduction in diastolic velocity integral (from 12.17 +/- 0.79 to 8.42 +/- 0.71 cm, p = 0.0067) and consequently left ventricular diastolic diameter (from 5.11 +/- 0.09 to 4.45 +/- 0.1 cm, p less than 0.0001). There was a significant reflex increase in heart rate from 59.9 +/- 1.9 to 77.1 +/- 2.4 beats/min (p less than 0.0001), but blood pressure was unchanged. This reduction in preload altered Doppler transmittral filling patterns as follows: 1) peak early velocity (E) decreased from 59.2 +/- 3.8 to 39.1 +/- 1.7 cm/s (p less than 0.0001); 2) atrial filing velocity (A) was unchanged (35.58 +/- 1.5 to 33.52 +/- 1.4 cm/s, p = 0.517); 3) E/A ratio decreased from 1.7 +/- 0.13 to 1.19 +/- 0.08 (p = 0.0087); 4) mean acceleration (from 482 +/- 37 to 390 +/- 27 cm/s2, p = 0.03) and mean deceleration (from 327 +/- 31 to 169 +/- 21 cm/s2, p less than 0.001) of the early filling wave were significantly reduced; and 5) peak acceleration (from 907 +/- 42 to 829 +/- 29 cm/s2) and peak deceleration (from 771 +/- 94 to 547 +/- 76 cm/s2) also decreased, but not significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and surgical correction of cor triatriatum in an adult: Combined use of transesophageal echocardiography and catheterization

This is an unusual case of a 37‐year‐old male whose initial presentation to medical care was for dyspnea. A transthoracic echocardiogram was suspicious for cor triatriatum, which was confirmed by transesophageal echocardiography. Since the resting transmembrane gradient was low, a cardiac catheterization with exercise hemodynamics was performed and demonstrated a marked increase in pulmonary capillary wedge and pulmonary artery pressures. The cor triatriatum was successfully resected at surgery. We have reviewed the English literature and find this to be a unique approach to diagnosis and management. Cathet. Cardiovasc. Intervent. 51:83–86, 2000.

A simplified method for determining regurgitant fraction by Doppler echocardiography in patients with aortic regurtitation

OBJECTIVES This study attempted to develop and validate a simple method for calculating aortic regurgitant fraction by use of pulsed wave Doppler echocardiography. BACKGROUND Although several investigators have been able to determine aortic regurgitant fraction by Doppler echocardiography, the methods used require accurate determination of the cross-sectional areas of intracardiac sites at which the volumetric flow is calculated. METHODS Our concept was based on a constant relation that exists between the cross-sectional area of the left ventricular outflow tract and the mitral valve annulus in normal subjects. To verify this, we used Doppler echocardiography to measure the flow velocity integral of the left ventricular outflow tract and the mitral annulus in the apical view in 50 normal subjects (32 men, 18 women, mean age 34 years). RESULTS Close correlation (r = 0.95) was observed between the flow velocity integral (FVI) of the outflow tract (OT) and that of the mitral annulus (MA): FVIMA/FVIOT = 0.77. Because mitral flow equals aortic flow in normal subjects, the ratio of the cross-sectional area of the mitral annulus to that of the outflow tract was 1/0.77. In patients with aortic regurgitation, the regurgitant fraction (RF) = (Aortic flow-Mitral flow)/Aortic flow = 1-Mitral flow/Aortic flow. Substituting 0.77 for the area component of flow, RF = 1-(1/0.77).(FVIMA/FVIOT). To evaluate the accuracy of this method, we compared the regurgitant fraction derived by Doppler echocardiography with that from catheterization findings in 20 patients with aortic regurgitation (an isolated lesion was found in 14). The regurgitant fraction by catheterization was the difference between total (angiographic) and forward (thermodilution) stroke volumes as a percent of total flow. Good correlation was observed between catheterization and Doppler regurgitant fraction (r = 0.88, SEE 9%, p < 0.01). CONCLUSIONS Thus, regurgitant fraction can be estimated from Doppler echocardiography in patients with aortic regurgitation by a method that requires only measurements of the flow velocity integral from the mitral annulus and left ventricular outflow tract.

Comparison of gray-scale and B-color ultrasound images in evaluating left ventricular systolic function in coronary artery disease

To confirm whether or not echocardiographic B-color images (temperature, magenta, rainbow) are superior to ordinary gray-scale images, 62 coronary artery disease (CAD) patients (42 men and 20 women) underwent gray-scale and B-color echocardiography and cineangiography within 24 hours. Left ventricular (LV) volume was derived from angiography using the single-plane area-length method and was derived from echocardiography using single-plane modified Simpsons formula. In predicting angiographic volume, the correlations between B-color images and angiography were similar to that between the gray-scale image and angiography. In evaluating LV ejection fraction, the correlation coefficients between B-color images and angiography (temperature r = 0.93, magenta r = 0.93, rainbow r = 0.92) were slightly higher than that between the gray-scale image and angiography (r = 0.85) (p less than 0.05). We conclude that B-color images yield estimates of LV volumes that are of similar accuracy to gray-scale images in patients with CAD.

Left atrial function in congestive heart failure: assessment by transmitral and pulmonary vein Doppler

The relation of transmitral flow patterns and pulmonary venous velocities was analyzed from 50 heart failure patients (28 men, 22 women; mean [±SD] age 61 ± 9 years) with a left ventricular ejection fraction < 40%. Doppler echocardiography was performed in all patients. Transmitral flow measurements included early (E) and atrial (A) velocities and deceleration time of E wave (DT). Patients were assigned to two groups according to E/A ratio, DT, or both: 20 patients in the restrictive group, and 30 patients in the nonrestrictive group. Pulmonary venous flow was obtained by the transthoracic approach. Systolic (S), diastolic (D) and atrial reversal (Ar) velocities were measured. Of the study population, 13 patients had simultaneously determined pulmonary capillary wedge pressure (PCWP).The results showed a lower S (28 ± 11 vs. 51 ± 10 cm/sec, p < 0.01), a higher D (66 ± 13 vs. 44 ± 10 cm/sec, p < 0.01) and a smaller Ar (12 ± 10 vs. 24 ± 9 cm/sec, p < 0.01) in the restrictive group compared with those in nonrestrictive group. In the subgroup of patients undergoing invasive hemodynamic studies, there was no relationship between PCWP and atrial reversal velocity. However, a significant correlation was observed for pulmonary systolic (r = -0.70, p < 0.01) and diastolic (r = 0.76, p < 0.01) velocities to PCWP. These findings suggest a reduction in left atrial compliance and atrial systolic function and both play important roles in heart failure patients with the restrictive transmitral flow pattern.

Pseudonormal or intermediate pattern

In 1988, Appleton et al. [(1)][1]investigated the relation between transmitral Doppler flow dynamics and invasively determined measurements of pressure and flow in a variety of heart diseases. Based on their findings, three abnormal transmitral flow patterns by Doppler echocardiography have been

Traumatic Communication Between Aorta and Left Atrium Diagnosed by Transesophageal Echocardiography

A45-year-old man was involved in a motor vehicle accident as an unrestrained driver. At the time of his arrival in the emergency room, he was hemodynamically stable but complained of severe chest pain and shortness of breath. A chest radiograph showed a wide mediastinum, and a CT scan of the chest suggested anterior mediastinal hemorrhage. A bedside transesophageal echocardiogram (TEE) performed in the emergency …