Nikolay P. Nikitin

Longitudinal ventricular function: normal values of atrioventricular annular and myocardial velocities measured with quantitative two-dimensional color Doppler tissue imaging.

OBJECTIVE Quantitative 2-dimensional color Doppler tissue imaging is a new method to reveal impairment of left ventricular (LV) and right ventricular (RV) longitudinal function, which is a potential marker of early myocardial disease. The aim of this study was to obtain normal values for atrioventricular annular and regional myocardial velocities using this method. METHODS A total of 123 healthy patients (age range: 22 to 89 years) underwent echocardiography including color Doppler tissue imaging using a scanner (Vivid 5, GE Vingmed, Horten, Norway) with postprocessing analysis (Echopac 6.3, GE Vingmed). Regional myocardial velocities were measured at 12 LV segments in 3 apical views and 2 segments of the free RV wall. Mitral annular velocities from 6 sites, and tricuspid annular velocities at its lateral site, were also assessed. At each site, systolic (S(m)), early diastolic (E(m)), and late diastolic (A(m)) velocities were measured, and the E(m)/A(m) ratio was calculated. RESULTS Patients were classified into 4 groups aged 20 to 39, 40 to 59, 60 to 79, and >/=80 years. Mitral annular velocity and regional LV myocardial S(m) and E(m) progressively decreased with age. A(m), whereas low in the youngest age group, increased significantly in patients more than 40 years of age. The E(m)/A(m) ratio gradually declined with aging. There were no differences between age groups in S(m) measured at the tricuspid annulus and free RV wall, but the pattern of age-related changes of diastolic velocities and E(m)/A(m) ratio was the same as in the LV. Slight but significant sex-related differences were observed in middle-aged groups. The intraobserver and interobserver reproducibility was highest for atrioventricular annular velocities. CONCLUSIONS A progressive decrease in S(m) reveals a decline in longitudinal systolic LV function with age, whereas systolic RV function remains unaffected. Atrioventricular annular velocity and regional E(m) decrease with aging in both ventricles, suggesting a deterioration in the diastolic properties of the myocardium, whereas A(m) increases from middle age implying a compensatory augmentation of atrial function. The study results can be used as reference data for the quantitative assessment of longitudinal LV and RV function in patients with cardiac disease.

Application of Tissue Doppler Imaging in Cardiology

Tissue Doppler imaging (TDI) is a new echocardiographic technique employing the Doppler principle to measure the velocity of myocardial segments and other cardiac structures. It is well suited for the measurement of long-axis ventricular function. Impairment of longitudinal myocardial fiber motion is a sensitive marker of early myocardial dysfunction and ischaemia, and TDI might therefore become an important tool in routine echocardiography. The technique allows truly quantitative measurement of regional myocardial function both at rest and during stress echocardiography. TDI has great potential in the diagnosis of diastolic left ventricular dysfunction, overcoming the load-dependence of conventional Doppler techniques. Right ventricular function, intracardiac and pulmonary artery pressures, transplant rejection and intraventricular dyssynchrony can also be assessed. This article reviews the current and evolving applications of TDI in cardiology.

Determinants and prognostic value of pulmonary arterial pressure in patients with chronic heart failure

AIMS The epidemiology of pulmonary arterial hypertension (PAH) in patients with heart failure (HF) is poorly described. Our aim was to investigate the determinants and prognostic significance of PAH in a large representative outpatient population with HF. METHODS AND RESULTS Routine measurement of right ventricular tricuspid pressure gradient (RVTG) was attempted among unselected, consecutive referrals to an HF clinic. The diagnosis of HF was based on symptoms, signs, echocardiography, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Of 2100 patients referred, 1380 were diagnosed as HF, of whom 1026 had left ventricular systolic dysfunction (LVSD) and 354 did not. Right ventricular tricuspid pressure gradient could be measured in 270 (26%) patients with and 143 (40%) without LVSD. The highest RVTG quartile [RVTG > 35 mmHg equivalent to an estimated PA systolic pressure (PASP) > 45 mmHg] constituted 7% of all those with HF and was associated with higher LV filling pressures, LV end-diastolic volume, LVSD, and more severe mitral regurgitation (MR). During a median (inter-quartile range) follow-up of 66 (56-74) months, mortality was 40.3%. Mortality was similar in the lowest quartile of RVTG and in those in whom RVTG could not be measured and rose with increasing RVTG quartile (log-rank: 26.9; P < 0.0001). The highest RVTG quartile, age, blood pressure, and log NT-proBNP independently predicted mortality. Right ventricular tricuspid pressure gradient >35 mmHg had a 96% specificity to discriminate between those with and without HF in patients without LVSD. CONCLUSION Using a definition of PASP > 45 mmHg, 7% of the patients with HF have PAH, which is associated with worse LV function, MR, and prognosis. Whether PAH is a target for therapy in this population remains to be elucidated.

Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

Objective: To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction. Methods: 185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging. Results: During a median follow up of 32 months (range 24–38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p  =  0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p  =  0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p  =  0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p  =  0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p  =  0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p  =  0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p  =  0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p  =  0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p  =  0.016) emerged as independent predictors of outcome. Conclusions: In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.

Color tissue Doppler-derived long-axis left ventricular function in heart failure with preserved global systolic function.

The mechanism causing symptoms and signs of heart failure (HF) in patients with preserved global left ventricular (LV) systolic function remains poorly defined. Conventionally, LV diastolic dysfunction is implicated as a major factor responsible for the clinical syndrome of HF in these patients, provided that valvular heart disease, cor pulmonale, volume overload conditions, and noncardiac causes of symptoms are excluded. 1 Early LV functional abnormalities can be detected using analysis of its longitudinal function 2,3 by M-mode echocardiography, magnetic resonance imaging, or tissue Doppler imaging. In the present study we investigated long-axis LV function in patients with symptoms of HF and preserved global LV systolic function using color tissue Doppler imaging. ••• From 220 consecutive attendees (14 women and 206 men, aged 68 12 years) referred to a HF clinic we identified 44 patients with signs and symptoms of compensated HF (New York Heart Association functional class II and III) and preserved global LV systolic function according to the criteria proposed by the European Study Group on Diastolic Heart Failure (LV ejection fraction 45% and LV end-diastolic diameter index 3.2 cm/m 2 or LV end-diastolic volume index 102 ml/m 2 ). 4 Twenty-five patients had ischemic heart disease (16 with previous myocardial infarction), 16 patients had a history of hypertension, and 3 patients were previously diagnosed with idiopathic dilated cardiomyopathy. All patients had been receiving diuretics and angiotensin-converting enzyme inhibitors or angiotensin II antagonists at optimal doses and had been stable for the preceding 3 months. We performed basic spirometry on all patients to exclude pulmonary disease. The control group was composed of 44 subjects (16 women and 28 men, aged 68 11 years) with no known cardiovascular disease. Each subject underwent full echocardiographic examination including color-coded tissue Doppler imaging using commercially available equipment (GE Vingmed Vivid Five scanner, Horten, Norway) equipped with a 2.5-MHz phased-array transducer. The parasternal long-axis view was used to derive left atrial dimension at end-systole. Measurements of LV end-diastolic volumes and end-systolic volumes were performed using the modified Simpson’ s rule and LV ejection fraction was calculated. Early filling (E) and atrial filling (A) peak velocities, E/A ratio, deceleration time of early filling, and isovolumic relaxation time were measured from transmitral flow, and systolic (S), diastolic (D), and atrial reversal peak velocities were derived from pulmonary venous flow using pulsed Doppler. In color tissue Doppler mode, images were obtained in 3 apical views (4-chamber, 2-chamber, and apical long-axis), and stored digitally on magnetic optical disks. The coded data were reviewed off-line with a software analysis system (Echopac 6.3, GE Vingmed). Mitral annular systolic velocities (S m), ignoring the

Clinical trials update: highlights of the scientific sessions of The American College of Cardiology 2002: LIFE, DANAMI 2, MADIT‐2, MIRACLE‐ICD, OVERTURE, OCTAVE, ENABLE 1 & 2, CHRISTMAS, AFFIRM, RACE, WIZARD, AZACS, REMATCH, BNP trial and HARDBALL

This article continues a series of reports updating recent research developments of particular interest to personnel involved in the treatment and management of patients with heart failure. This is a summary of selected presentations made at the American College of Cardiology 51st Annual Scientific Session held in Atlanta on 17–20 March 2002. Reports of the following clinical studies are included: LIFE, DANAMI 2, MADIT‐2, MIRACLE‐ICD, OVERTURE, OCTAVE, ENABLE 1 & 2, CHRISTMAS, AFFIRM, RACE, WIZARD, AZACS, REMATCH, BNP trial and HARDBALL.

Lack of Diastolic Reserve in Patients With Heart Failure and Normal Ejection Fraction

Background—The genesis of symptoms in patients with heart failure (HF) and normal ejection fraction (HFNEF) is unclear. Most investigations of HFNEF have focused on cardiac function at rest although most of these patients are breathless only on exercise. Stress-induced impairment in systolic or diastolic function could result in these symptoms. Method and Result—Forty-one patients with HFNEF and 29 controls underwent dobutamine stress echocardiography with color tissue Doppler imaging. Wall motion score index and regional myocardial systolic velocity (Sm) were measured at and peak stress. Systolic (Sa), early diastolic (Ea), and late diastolic (Aa) mitral annular velocities were averaged over the 6 periannular sites. Mitral annular long-axis velocity was lower in the HFNEF than controls at rest. Global, regional, and long-axis systolic function did not worsen with stress in the HFNEF group. The Ea decreased and the E/Ea increased with stress in the HFNEF but not in controls. The 6-minute walk distance was shorter and negatively correlated to the E/EA ratio at rest and stress in the HFNEF group. Conclusion—Impaired diastolic reserve results in stress-induced increase in the left ventricular end-diastolic pressure in patients with HFNEF giving rise to exercise intolerance.

Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure.

The aim of this study was to investigate the prognostic impact of right ventricular (RV) size in patients with chronic heart failure.

Excessive breathlessness in patients with diastolic heart failure

Objectives: To establish the prevalence of preserved left ventricular (LV) systolic function (PSF) in 435 consecutive symptomatic patients referred to a heart failure clinic and to examine their ventilatory response to exercise when compared with 134 control volunteers. Methods: 216 (50%) patients had systolic heart failure (SHF) (ejection fraction < 45%). 51 (11%) had an immediately apparent alternative causes of breathlessness and 168 (39%), with no obvious other cause of breathlessness, were divided into those with PSF and diastolic dysfunction (DD) (PSFDD; n  =  113 or 26% of referrals) and those without DD (PSFN; n  =  55 or 13% of referrals). The controls were divided into those with (CDD; n  =  32) and those without (CN; n  =  102) echocardiographic evidence of DD. Results: Patients with SHF had lower peak oxygen consumption (pV̇o2), steeper slope of minute ventilation (V̇e) to carbon dioxide production, lower exercise time and shorter 6 min walk test than PSF patients and controls. PSFDD patients had lower pV̇o2, exercise time and 6 min walk test than CDD, although their echocardiograms were not different. Exercise capacity did not differ between PSFDD and PSFN patients. The slope relating V̇e to symptoms (Borg/V̇e slope) was less steep in those with SHF than in PSFDD (0.17 (0.04) v 0.20 (0.08), p < 0.05) and in PSFN (0.19 (0.10), p < 0.05), implying greater symptoms of breathlessness for a given level of V̇e. Both PSF groups had a steeper slope than CDD (0.14 (0.09), p < 0.05 for both comparisons). Conclusions: Patients with PSF have exercise tolerance intermediate between that of patients with SHF and controls. Exercise tolerance is similar in PSFDD and PSFN. Both groups have worse exercise tolerance than CDD. PSFDD and PSFN patients seem to experience a greater awareness of V̇e than CDD and patients with SHF.

The effects of long-term β-blockade on the ventilatory responses to exercise in chronic heart failure

Chronic heart failure (CHF) patients complain of breathlessness and fatigue. Beta‐blockers improve symptoms, echocardiograpahic variables and prognosis in CHF, but their effect on exercise capacity remains unclear. The aim of this study was to describe the effects of long‐term beta‐blocker therapy on metabolic gas exchange variables and ventilation during exercise in CHF patients.