Estimation of Left Ventricular End-Diastolic Pressure by Color M-Mode
Doppler Echocardiography and Tissue Doppler Imaging
Sinan Dagdelen, MD, Nevnihal Eren, MD, Hasan Karabulut, MD, Ilyas Akdemir, MD, Mehmet Ergelen, MD, Mustafa Saglam, MD, Murat Yiice, MD, Cem Alhan, MD, and
Nuri Caglar, MD, Istanbul, Turkey,
Objectives: The a im o f th is s tudy was to e s t ima te left v e n t r i c u l a r end-d ias to l ic p r e s s u r e (LVEDP) non inva -
s ive ly b y t i ssue D o p p l e r imag ing a n d c o l o r M-mode e c h o c a r d i o g r a p h y .
Material and Methods: We s tud ied 3 g r o u p s o f pa t i en t s w h o w e r e p r o v e n b y a n g i o g r a p h y to be f ree o f signi- f icant c o r o n a r y a r t e r y les ions (<40% s tenos i s ) w i t h a n LVEDP < 10 m m Hg (g roup A: n = 24; 16 men , 18
w o m e n ; m e a n age • SD = 55 + 13 years) , an LVEDP o f 10 to 15 m m Hg (group B: n = 21; 17 men , 4 w o m e n ; m e a n age 56 + 11 years) , o r an LVEDP > 15 m m Hg (group C: n = 35; 20 men , 15 w o m e n ; m e a n age 58 + 9 years ) . Tissue D o p p l e r imag ing o f the l a te ra l m i t r a l a n n u l u s and c o l o r M - m o d e i m a g i n g o f t h e m i t r a l va lve in the apica l 4 - c h a m b e r v i e w w e r e o b t a i n e d w i t h an e c h o c a r d i o g r a p h i c sys tem. Ear ly a n d la te d ias to l i c ve loc i t i es (Em a n d Am, r e spec t ive ly ) , Em d e c e l e r a t i o n t i m e (EmDT), A m t i m e (Am-t) , a n d mi t r a l p r o p a g a t i o n ve loc i ty t ime de l ay (VpDT) w e r e m e a s u r e d in each pa t ien t .
Results: In g r o u p A, s ens i t i v i t y a n d spec i f i c i t y fo r EmDT _< 100 ms, Am-t _< 90 ms, Era /Am >_ 1, and VpDT -< 45 ms were found to be 0.57 and 0.89, 0.66 and 0.88, 0.86 a n d 0.92, a n d 0.73 a n d 0.89, r e spec t ive ly . In g roup B, sensi t iv i ty and specif ic i ty for EmDT 100 to 120 ms, Am-t 90 to 110 ms, Era /Am I to 0.5, and VpDT 45 to 60 ms were found to be 0.57 and 0.84, 0.69 and 0.82, 0.66 and 0.75, a n d 0.55 and 0.83, respect ively . In g r o u p C, sens i t iv i ty and specif ic i ty for EmDT > 120 ms, Am-t > 110 ms, E m / A m < 0.5, and VpDT > 60 m s were found to be 0.88 and 0.81, 0.71 a n d 0.80, 0.86 and 0.72, a n d 0.78 a n d 0.86, respect ively . Conclusion: The EmDT, Am-t, E m / A m , a n d VpDT m e a s u r e m e n t s o b t a i n e d n o n i n v a s i v e l y b y lef t ven t r i cu l a r t issue D o p p l e r ima g ing a n d m i t r a l f low p r o p a g a t i o n ve loc i ty w e r e f o u n d to be usefu l in the e s t i m a t i o n o f LVEDP. (J Am Soc Echocardiogr 2001; 14:951-8.)
I N T R O D U C T I O N
Left ven t r icu la r diastol ic dysfunc t ion is k n o w n to be a s ign i f i can t c a u s e o f c a r d i a c s y m p t o m s , e v e n in p a t i e n t s w i t h n o r m a l lef t v e n t r i c u l a r func t ion . I , 2 E c h o c a r d i o g r a p h y n o t on ly p r o v i d e s a n a t o m i c and func t iona l in fo rmat ion bu t is also a safe, inexpens ive , and w i d e l y avai lable imag ing modal i ty . Recently, it has b e e n used to evaluate var ious diastol ic func t ion
pa r a me te r s such as left ven t r icu la r filling, p u l m o n a r y venous f low indexes , and left ven t r icu la r filling pres- sure, r e l axa t ion , and stiffness.3~6 T h e s e p a r a m e t e r s are used no t only for d iagnos t ic p u r p o s e s bu t also to es tabl ish the p rognos i s and to evaluate the effect of t he rapeu t i c in te rvent ions . 7-9 Pulsed D o p p l e r record- ings o b t a i n e d f rom t h e mi t ra l valve a n d t h e pul- m o n a r y ve ins have b e e n s h o w n to c o r r e l a t e we l l w i t h cer ta in h e m o d y n a m i c findings, and these data signif icantly c o n t r i b u t e d to e i the r cl inical approach- es o r n o n i n v a s i v e h e m o d y n a m i c predict ion.3,10A 1 On the o t h e r hand, D o p p l e r f low indexes are h ighly in f luenced by cer ta in phys io log ic var iables (eg, hea r t rate, a f te r load , p r e l o a d , i n t r avascu la r vo lume) , and the in te rac t ion b e t w e e n the indexes and these vari- ables, w h i c h is some t imes misleading, is difficult to d iscern . 12,13 It may be mis leading to p red i c t dias tol ic
9 5 1
Journal of the American Society of Echocardiography 952 Dagdelen et al October 2001
E C G
/ ? C M M
!¥
Vp
VpDT
Figure 1 Measurement of the time delay of the mitral propagation velocity (VpDT) with the use of the color M- mode Doppler (CMM) method. ECG, Electrocardiogram; Vp, flow propagation velocity; Va, atrial flow propagation velocity.
f u n c t i o n o n the basis of the mi t ra l f l ow ve loc i ty w h e n left vent r icular end-diastolic pressure (LVEDP)
increases moderately. At such a t ime, left atrial pres- sure increases and exceeds LVEDP, resul t ing in the pseudonormal iza t ion pat tern. 14
Tissue Doppler imaging (TDI) and color M-mode
Dopple r (CMM), wh ich are b e c o m i n g more popular, are k n o w n to be i n f luenced less by physiologic vari- ables. 15,16 For this reason, they may provide more
sensitive informat ion about the left ventr icular relax- at ion disorders. 17 Left ventr icular end-diastolic pres- sure increases in many systemic and cardiovascular diseases. It is also a valuable tool in establishing the
t rea tment or de t e rmin ing the cardiac prognos is .The
aim of this study was to predict LVEDP noninvasively
by using TDI and CMM techniques .
MATERIAL AND METHODS
Patient Se lect ion
The study group consisted of patients who had none of the following: critical coronary artery lesions (<40% steno- sis) confirmed by cardiac catheterization, structural mitral valve disease, segmental wall motion abnormality, or previ-
women) who met the above-mentioned criteria under-
went a standard bedside echocardiographic examination within 15 minutes before catheterization. The patients were categorized into 3 groups on the basis of their LVEDP
measured at the catheterization: group A subjects had an
LVEDP < 10 mm Hg (n -- 24; 16 men, 8 women), group B subjects had an LVEDP 10 to 15 mm Hg (n = 21; 17 men,4 women), and group C subjects had an LVEDP > 15 mm Hg
(n = 35; 20 men, 15 women). Hypertension was present in
5 patients in group A (21%), in 9 patients in group B (43%), and in 25 patients in group C (71%), and all of these patients were taking angiotensin-converting enzyme inhi-
bitors. After catheterization, 25 mg of captopril was given
when needed. All patients were in normal sinus rhythm.
Echocard iography
Two-dimensional and M-mode echocardiographic parame-
ters were obtained with anAloka SSD 2200 device (Tokyo,
Japan). Parasternal long- and short-axis views and apical 2- and 4-chamber views were used for evaluating left ven- tricular and valvular function. Pulsed and continuous wave
Doppler examinations were made with a 2.5-MHz sector transducer. For the CMM examination, the Doppler cursor
was placed somewhere between the mitral valve opening
plane and the apex in the apical 4-chamber view, and early and late diastolic recordings were obtained with simulta- neous electrocardiography.An average value was obtained from recordings of 5 to 8 consecutive cardiac cycles.The flow propagation velocity, defined as the velocity leading
edge of the early-filling wave (transition from no color to
color), was measured from the mitral leaflet tips to the apex. The time delay of the mitral propagation velocity (VpDT), def'med as the beginning to the peak point of the
color convergence, was calculated with use of the ob-
tained flow pattern (Figure 1). The pulsed wave spectral mode was used forTDI. Filters
and baselines were corrected when the velocity ranged between -20 and 20 cm/s. From the apical 4-chamber view, a 5-ram sample volume was placed at the lateral cor- ner of the mitral annulus. An average value was obtained
from the recordings of 5 to 8 consecutive cardiac cycles
with simultaneous electrocardiography. Early (Em) and late
(Am) diastolic velocities, Em/Am, Em deceleration time (EmDT), and Am time (Am-t) were calculated from TDI recordings. The measurements were obtained and record-
ed as shown in Figures 2 and 3.
Cardiac Catheter izat ion
Left and right heart catheterization and left-right coronary angiography were performed via the femoral artery by using a Siemens Coroscop Hicor system (Munich, Germany). A mean LVEDP was obtained from 5 consecu- tive pressure recordings. Left ventricular pressure was
measured with a 6F micromanometer-tipped catheter
Journal of the American Society of Echocardiography Volume 14 Number 10 Dagdelen et al 9 5 3
ECG
T D I Sm Am-t EmDT
~m Figure 2 Measurement o f the early (Em) and late (Am) myocardial diastolic velocities, E m / A m ratio, and Em deceleration time (EmDT) in the mitral lateral annulus tis- sue Dopp le r imaging (TDI) recording. ECG, Electro- cardiogram; Sm, systolic myocardial velocity; Am-t, Am time.
ence was set at the pat ient hear t level. Then the line
be tween catheter and transducer was opened, and the left
ventricular pressure tracing was recorded with simultane-
ous electrocardiography. The pressure tracing was record-
ed by using a Siemens CD-7000 moni tor (Siemens-Recor
449Xi Plus system, Munich, Germany) at a paper speed of
50 mm/s. An average pressure value was obtained from 5
consecutive pressure records.
Ana lys i s
No deFmitive data are available in the literature regarding
the assessment of the left ventr icular diastolic funct ion
with TDI and CMM. Several previous studies have shown
that an Em/Am ratio <1 is a power fu l p red ic to r of a
p seudonorma l res t r ic t ive left vent r icular filling pat-
tern. 18,19 Klein et a120 demonstrated that a mitral E/A ratio
< 0.5 correlates well wi th stage III left ventricular diastolic
dysfunction. Stugaard et a121 demonstrated an increase in
dogs inVpDT from 34 _+ 5 ms to 156 -+ 16 ms with induced
coronary ischemia (P < .001), indicating a marked delay of
apical diastolic filling. Oki et a122 demonstrated a signifi-
cant increase in mitral early diastolic filling acceleration
t ime (which is the same time interval in the cardiac cycle
as that used to determine EmDT) in patients wi th E/A _> 1 (89 -+ 11 ms) compared with patients wi th E/A < 1 (111 _+
22 ms).
In assessing the relation be tween LVEDP and echocar-
diographic (TDI and CMM) parameters, certain limits for
the groups were determined as follows. Group A consisted
E t
r ,
I | '
(,
Vp
Va
F i g u r e 3 I l lustrat ion o f the mitral flow pat tern and Doppler values in standard Doppler (A), in tissue Doppler imaging (B), and in color M - m o d e Doppler (C). Em, Early diastolic myocardial Doppler velocity; Am, late dia- stolic myocardial Doppler velocity; VpDT, t ime delay o f the mitral p ropagat ion velocity; Vp, f low propagat ion velocity; Va, atrial flow propogat ion velocity.
of subjects with EmDT _< 100 ms,Am-t _< 90 ms, Em/Am >
1, and VpDT < 45 ms. Group B subjects had the following
values: EmDT 100 to 120 ms,Am-t 90 to 110 ms, Em/Am 1
to 0.5 (for this group, 1 is out and 0.5 is in), and VpDT 45
to 60 ms.Values for group C subjects were EmDT > 120
ms,Am< > 110 ms, Em/Am < 0.5, andVpDT > 60 ms.
Sta t i s t ica l Ana lys i s
All data were expressed as the mean +_ SD. Statistical sig-
nificance was set at P < .05 with a 95% confidence inter-
val. Statistical analysis of the parametric values be tween
groups was made by unpaired t test.To compare the non-
Journal of the American Society of Echocardiography 954 Dagdelen et al October 2001
Table 1 Echocardiographic parameters and LVEDP of the study groups (n = 80)
EmDT Am-t VpDT LVEDP Group Em/Am (ms) (ms) (ms) ( r am Hg)
A 1.35 ± 0.45* 89 + 19" 83 + 19" 43 _+ 12" 8.5 ± 1.4" B 0.81_+ 0 .22 t 1 1 0 ± 1 6 t 1 0 5 ± 1 6 t 5 7 + 1 6 t 1 2 . 9 + - 1 . 3 t
Em, Early diastolic myocardial Doppler velocity; Am, late diastolic myocar- dial Doppler velocity; EmDT, Em deceleration time; Am-t, Am time; VpDT, time delay of the mitral propagation velocity; LVEDP,, left ventricu- lar end-diastolic pressure. *Group A vs group B: P < .001; group A vs group C: P < .001. tGroup B vs group C: P< .01.
parametric values of the groups, variance analysis and chi- square tests were used where applicable. The relation of
the parameters within the groups was analyzed with a lin- ear correlation test. Sensitivity and specificity for limit val-
ues of each group were calculated.
~ S ~ T S
All 3 groups were comparable in regards to age, sex, and heart rate. Respective values for groups A, B, and
C were as follows.The m e a n ages were 55 + 13 years, 56 _+ 11 years, and 58 _+ 9 years (P = no t significant
INS]). The pe rcen tages of w o m e n were 33%, 19%, and 43% (P = NS).The m e a n hear t rates were 71 _+ 10 bpm, 78 _+ 20 bpm, and 76 _+ 12 b p m (P = NS).The
m e a n systolic b lood pressures were 129 _+ 18 m m Hg, 137 -+ 26 m m Hg, and 150 _+ 26 m m Hg (group A
versus B: P = NS; group B versus C: P = .04; and group A versus C: P = .001).The m e a n diastolic b lood pres- sures were 73 -+ 10 m m Hg, 82 _+ 12 m m Hg, and 91 +_. 16 m m Hg (group A versus B: P = .006; group B ver-
sus C: P = .019; and group A versus C: P = .0001). Hyper tens ion was p resen t in 5 (21%), 9 (43%), and
25 (71%) pat ients (group A versus B: P = NS; group B versus C: P = .03; and group A versus C: P = .0001).
E c h o c a r d i o g r a p h i c F i n d i n g s
Tissue D o p p l e r imag ing and CMM f ind ings w e r e
compared wi th each o ther in the 3 groups (Table 1). Em total t ime was s imilar in all g roups (P = NS). However, the m e a n EmDT and Am-t were the longest
in group C and the shortest in group A. In groups A, B, and C, respectively, Em was 12.4 _+
3.9 cm/s, 10.2 _+ 2.7 cm/s, and 6.7 _+ 3.7 cm/s; Am
was 9.3 +- 1.3 cm/s, 12.9 +- 2.1 cm/s, and 13.9 +- 2.3 cm/s; and EmT was 176 -+ 30 ms, 179 + 28 ms, and
190 -+ 35 ms. The Em/Am ratio was the smallest in group C and
the h ighes t in g roup A. The m e a n VpDT was the
Table 2 Distribution of patients according to echocardio- graphic parameters
Em, Early diastolic myocardial Doppler velocity; Am, late diastolic myocar- dial Doppler velocity; EmDT, Em deceleration time; Am-t, Am time; VpDT, time delay of the mitral propagation velocity.
longest in group C and the shortest in groupA.AU these differences were statistically significant (Table 1). The
distribution of the Doppler parameters obtained from our study is shown inTable 2.The sensitivity and speci- ficity of the Doppler parameters in detecting various
levels of LVEDP are shown in Table 3. The l inear co r re l a t ions of TDI and CMM w i t h
LVEDP were investigated. In groups A, B, and C, a sig-
nif icant correlat ion was found b e t w e e n LVEDP mea- su r e me n t s and values of EmDT, Am-t, Em/Am, and VpDT. These cor re la t ion coeff icients are s h o w n in
Table 4.
DISCUSSION
It is well k n o w n that a s trong relat ion exists b e t w e e n mit ra l diastol ic f l ow and left ve n t r i c u l a r diastol ic
func t ion . The diastol ic f i l l ing p a t t e r n is typica l ly impai red w i th elevated left vent r icu lar filling pres- sure. 23-26 Left vent r icular end-diastolic pressure still
n e e ds to be m e a s u r e d du r ing cardiac catheter iza- tion. Previous studies mainly focused o n mitral dia-
stolic f low and p u l m o n a r y venous f low pa t te rns in est imating LVEDP 27-31 However, recent advances in
Dopple r echocardiography have made it possible to
es t imate LVEDP non i nva s i ve l y in ce r t a in p a t i e n t groups. Recently, useful insight into the s tudy of dia- stolic func t ion has b e e n at ta ined wi th the use of TDI and CMM. Left ven t r i cu la r diastolic filling is influ- enced less by the physiologic variables withTD1 and
Journal of the American Society of Echocardiography Volume 14 Number 10 Dagdelen et al 955
Table 3 Sensitivity (Se) and specificity (Sp) between Doppler parameters and groups
Era, Early diastolic myocardial Doppler velocity; Am, late diastolic myocar- dial Doppler velocity; EmDT, Em deceleration time; Am-t, Am time; VpDT, time delay of the mitral propagation velocity.
C M M . T M These n e w D o p p l e r app l i ca t ions have
b e e n s h o w n to provide an accurate estimate of left ven t r i cu la r re laxat ion, and they appear to be rela-
tively insensi t ive to the effects of preload compensa- tion.3,14,17
Apple ton et al3 studied the relat ion of transmitral f l ow ve loc i ty p a t t e r n to left ven t r i cu l a r diastol ic func t ion . In the i r c o m b i n e d h e m o d y n a m i c and
Dopple r echocardiographic study, the correlat ions of LVEDP wi th isovolumetr ic relaxat ion time, transmi- tral E decelera t ion time, andA veloci ty were found to
be r --- -0.42, -0.48, and -0.43, respectively.The main
cause of these negative correlat ions was that only 30 of the total 70 subjects were healthy, bu t the o ther
subjects had coronary hear t disease that resul ted in dilated cardiomyopathy, restrictive cardiomyopathy, and /o r left vent r icular systolic dysfunct ion .Al though
the re was a w e a k nega t ive co r re l a t ion b e t w e e n LVEDP and t ransmi t ra l f low and t ime intervals , Nagueh et al32 found a strong correlat ion b e t w e e n
p u l m o n a r y capillary wedge pressure and the ratio of t ransmi t ra l E ve loc i ty to Em ( r = 0.86), and they showed a good correlat ion b e t w e e n these Dopple r and cardiac catheter izat ion parameters . In addition,
in a group of pat ients wi th hyper t rophic cardiomy- opathy, a s trong correlat ion was found b e t w e e n left vent r icular Filling pressure and the ratio of transmi-
tral E ve loc i ty to f l ow p r o p a g a t i o n ve loc i ty ( r = 0.76), and also b e t w e e n left ventr icular filling pres-
sure and the ratio of transmitral E velocity to Em (r = 0.82) wi th the use of TDI and CMM. 33 Tissue Doppler
Table 4 Correlation coefficients (r) between Doppler parameters and LVEDP
Group A Group B Group C (r) (r) (r)
E m D T (ms) 0.67 0.55 0.63 Am-t (ms) 0.72 0.59 0.66 E m / A m -0 .76 ~) .66 -0 .61 VpDT (ms) 0.69 0.63 0.65
P < .01 for all. Em, Early diastolic myocardial Doppler velociw; Am, late diastolic myocardial Doppler velocity; EmDT, Em deceleration time; Am-t, Am time; VpDT, time delay of the mitral propagation velocity; LVEDP, left ventricular end-diastolic pressure.
imaging and CMM have also b e e n s h o w n to be use-
ful in predic t ing left atrial pressure and left ventr icu- lar fi l l ing pressure . 11,34 O ur s tudy s u p p o r t s the
above-ment ioned studies wi th the fol lowing results: 1. The parameters of EmDT _ 100 ms, Am-t _ 90
ms, Em/Am _> 1, and VpDT ___ 45 ms are moder-
ately sensitive and highly specific for detec t ing an LVEDP _< 10 m m Hg.
2. The parameters of EmDT 100 to 120 ms, Am-t 90
to 110 ms, Em/Am 1 to 0 .5 ,andVpDT 45 to 60 ms are moderate ly sensitive and highly specific for
detec t ing an LVEDP b e t w e e n 10 to 15 m m Hg. 3. The parameters of EmDT > 120 ms,Am-t > 110
ms, Em/Am < 0.5, and VpDT > 60 are highly sen-
sitive and specific for detec t ing an LVEDP _ 10
m m Hg. 4. Each of our 3 groups had a significant correla t ion
b e t w e e n LVEDP m e a s u r e m e n t s and values of EmDT, Am-t, Em/Am, and VpDT.
Oki et a122 demons t ra ted a significant increase in
mit ra l early diastol ic f i l l ing acce le ra t ion t ime in pat ients wi th mitral E/A < 1. They measured mitral
early diastolic filling accelerat ion t ime as 89 + 11 ms in pat ients wi th mitral E/A > 1. This t ime interval in
the cardiac cycle is the same as the interval used to d e t e r m i n e EmDT. We eva lua ted pa t i en t s w h o had EmDT _ 100 and Em/Am _> 1 and found a modera te
sensitivity and a high specificity for detec t ing LVEDP
_< 10 m m Hg. B r u n e t a135 identif ied the leading edge of the early
filling wave, measured from the mitral leaflet tips to the apex, as the f low propaga t ion velocity (Vp) by using the CMM method. In their study, they demon-
strated a significant negative correlat ion b e t w e e n Vp
and the t ime cons tan t of relaxat ion in various groups of pat ients wi th coronary heart disease and cardio- myopathy. These f indings suggest that Vp ob ta ined from CMM may represent a useful noninvas ive index for assessing left ventr icular relaxation. Fur ther stud-
ies identif ied the tempora l difference b e t w e e n the po in t of maximal velocity at the mitral level and at
Journal of the American Society of Echocardiography 956 Dagdelen et al October 2001
the apex, and they also demonstrated that this time delay (VpDT) was prolonged significantly in dogs during ischemia induced by coronary occlusion and in human subjects undergoing coronary angioplas- ty. 21,36 In our study, in patients with high LVEDP, VpDT tended to increase significantly, parallel with the severity of the left ventricular diastolic dysfunc- tion. In a great majority of patients with restrictive cardiomyopathy, Garcia et a117 observed the Em/Am ratio to be <1 in patients with pseudonormalized or restrictive filling and an E/A ratio > 1. Sohn et all9 measured myocardial velocities in healthy volunteers as well as in patients with delayed relaxation and pseudonormal left ventricular filling, as assessed by Doppler mitral inflow variables and invasive hemo- dynamic measurements. In patients with a mitral Doppler inflow pattern of delayed relaxation, the infusion of volume resulted in a change toward pseudonormalization, with shortening of the E-wave deceleration time and an increase in the E/A ratio, whereas patients with normal or pseudonormal fdl- ing at baseline demonstrated a significant reduction in mitral inflow E velocity and E/A ratio after nitro- glycerin infusion. In contrast, they found no signifi- cant changes in Em velocity, confirming that this parameter is less sensitive to preload changes. In that study, patients with pseudonormal filling, defined as the combination of normal mitral inflow variables and prolonged z (>50 ms), could be distinguished from patients with normal filling patterns by an Em velocity < 8.5 cm/s and an Em/Am ratio < 1, with a sensitivity of 88% and a specificity of 67%. In our study, comparisons between LVEDP measurements andTDI and CMM parameters showed moderate cor- relation in all groups, moderate sensitivity in groups A and B and high sensitivity in group C, and high specificity in all groups.
Our study population consisted of patients with no significant coronary artery disease on coronary angiography, no history of myocardial infarction, and no systolic segmental left ventricular wall motion abnormality.Thus LVEDP differences in the 3 groups seem mainly to be the result of hypertension, as we have found no additional pa thology which may increase the LVEDP in these patients. Indeed, the incidence and the severity of hypertension were sig- nificantly different among the 3 groups. It is well known that hypertension causes fibrotic changes in the left ventricular subendocardium, resulting in left ventricular diastolic dysfunction.37,38 Furthermore, it has been demonstrated that elevated left ventricular pressure and increased left ventricular wall stress lead to diastolic heart failure in hypertension.39,40
Clinical I m p l i c a t i o n
Previous studies have focused on new echocardio- graphic parameters in estimating the LVEDP. How- ever, there are still no numeric data available that show the superiority of TDI and CMM in estimating LVEDP. The high sensitivity and specificity of TDI and CMM encourage the use of echocardiography in estimating the LVEDP.These parameters may become popular in the near future because they are simple, inexpensive, and noninvasive. Moreover, bedside availability of LVEDP will be an important tool in the diagnosis and treatment of heart diseases and also in the differentiation of systolic and diastolic dysfunc- tion, which may mimic each other clinically.
Limi ta t ions
The TDI and CMM parameters in the assessment of left ventricular diastolic function are not well de- fined. The ranges of these parameters need to be determined in various age and disease groups. The effects of calcium channel blocker and beta blocker therapy onTDI and CMM parameters also need to be evaluated with comparative studies.
In this study, tissue Doppler recordings were obtained only from the mitral lateral annulus; how- ever, it is not clear that left ventricular end-diastolic stress is equally distributed to every segment. In addi- tion, the increase in the wall thickness is propor- tional in every segment in hypertensive patients.The effects of duration and severity of hypertension on echocardiographic parameters were not evaluated in this study; however, a study is being performed by our group regarding the correlation of left ventricu- lar mass index with Doppler parameters.
C o n c l u s i o n
New Doppler echocardiographic applications, TDI and CMM, are more valuable tools than conventional Doppler applications for the assessment of left ven- tricular diastolic function. In the estimation of LVEDE these new parameters had a moderate sensi- tivity in our groups A and B, a high sensitivity in group C, and a high specificity in all groups. In addi- tion, they have moderate correlation with LVEDP. Tissue Doppler imaging and CMM applications ap- pear to increase the value of new echocardiographic methods in noninvasive estimation of hemodynamic parameters.
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