Evaluation of Left Ventricular Diastolic Dysfunction by Doppler and 2D Speckle-tracking Imaging in Patients with Primary Pulmonary Hypertension
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1 ESC Congress 2011.No Evaluation of Left Ventricular Diastolic Dysfunction by Doppler and 2D Speckle-tracking Imaging in Patients with Primary Pulmonary Hypertension Second Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan Konomi Sakata, Kazuki Sato, Toshinori Minamishima, Kazuya Takemoto, Junsuke Sueoka, Touru Sato, Hideaki Yoshino Presenter - from 08:30 to 12:30. 28/08/2011 Room: Posters - Poster Zone C Sess. Title : Poster session 1. Pres. N : / from 08:30 to 12:30
2 Abstract Background: In patients with Primary Pulmonary hypertension (PPH), RV pressure overload causes right ventricular dilation and left ventricular (LV) cavity reduction. OBJECTS: We sought to investigate the LV diastolic dysfunction using Doppler and 2D speckle- tracking imaging (2DSTI) in patients with PPH. Methods: We performed Doppler and speckle-tracking imaging in 38 patents with PPH ( PH) and 18 control subjects ( N:30.6±4.6 years). Fifteen ( PH-HF) of 38 patients in PH were complicated with right heart failure, and other 23 patients ( PH-N) were not complicated. We measured early and late diastolic peak velocities of mitral inflow (E and A), and deceleration time (DT), and the mitral annular velocities (e ) in two sites by tissue Doppler imaging, and the ratio of early mitral inflow to mitral annular velocity (E/e'). Global LV peak relaxation strain rate (RSR) during early diastole were analyzed by 2DSTI in the longitudinal direction. Results: E (60.5±3.5 vs. 84.3±3.5 cm/s : p < ) and E/A (0.8±0.07 vs. 1.8±0.7: p < ) were significantly lower in PH than in N. DT (181.2±43.7 vs ±31.5 ms: p= ) was longer in PH. e (14.3±0.6 vs. 8.8±0.5 cm/s : p< ) was lower and E/e (7.8±0.4 vs. 5.9±0.4: p = ) was higher in PH than in N. RSR was significantly lower in PH (0.9±0.1 vs. 1.4±0.1: p = ). Conclusion: LV diastolic dysfunction appeared in patients with PPH. RV pressure overload and reduction of RV output caused impaired LV filling.
3 Cardiac Dysfunction in Patients with Pulmonary Artery Hypertension pulmonary vascular resistance increase Pulmonary artery pressure increase RV afterload increase RV dilatation RV free wall tension increase RV hypertrophy abnormal curvature of interventricular septum LV compliance decrease Preload reserve limit afterload mismatch Tricuspid regurgitation LV output reduced RV ischemia RV output reduce RV: right ventricular, LV: left ventricular
4 Background Pulmonary arterial hypertension (PAH) Primary pulmonary arterial hypertension (PAH) is characterized by obstructive lesions of the small pulmonary vessels leading to increased pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP). The elevations of PVR and PAP causes right ventricular (RV) pressure overload, which leads to functional and morphologic alterations of both RV and left ventricle (LV), such as increased RV end-diastolic volume (RVEDV) and LV chamber distortion (decreased LV end-diastolic volume (LVEDV) and flattening or leftward displacement of the interventricular septum). These changes result in a decreased cardiac output, and eventually leads to cardiac failure and death.
5 Background Left Ventricular Dysfunction in Patients with Pulmonary Arterial Hypertension (PAH) The decrease in LVEDV is a consequence of impaired LV filling in IPAH. Impaired LV filling in RV pressure overload state might be the result of a decrease of stroke volume or compression of the LV due to an increased RVEDV. The decrease in LVEDV is strong predictors of mortality in IPAH. (European Heart Journal 2007;28, ) In PAH patients with decreased LVEDV, the quantitative assessment of global and regional LV myocardial function is important to evaluate impaired LV filling and LV diastolic dysfunction.
6 Pulmonary artery hypertension (PAH) causes right ventricular (RV) pressure overload, which leads to functional and morphologic alterations of both right and left ventricles (LV). These changes result in a decreased cardiac output, and leads to cardiac failure. Right ventricular (RV) pressure overload inceases RV end diastolic volume (RVEDV) causesthe abnormal LV diastolic function seen in a state was a consequence of a decrease of stroke volume, and compression of the LV due to an increased RVEDV in patients with PAH.
7 Background Tissue Doppler Imaging (TDI) The mitral annular systolic (s ) and early (e ) and late (a ) diastolic myocardial velocities were acquired in apical fourchamber views at the junction of the left ventricular free wall and the leaflet of the mitral valve using tissue doppler imaging (TDI). The mitral annular doppler velocities can evaluate LV diastolic function noninvasively and quantitatively. Eur Heart J 2001;22: Echocardiography 2008;25: J Am Soc Echocardiogr 2004;17: Echocardiography 2006;23:750 5.
8 Background Strain and Strain Rate by Two-Dimensional Speckle Tracking Imaging Two-dimensional speckle tracking imaging (2DSTI) is a reliable and feasible technique of tracking myocardial deformation angle-independently and allowing a comprehensive and quantitative assessment of global and regional myocardial function. (Cardiovasc Ultrasound ;5:27. ) Strain and strain rate by two-dimensional speckle tracking imaging (2DSTI) may be useful for quantitative evaluation of LV and RV function in patients with PAH.
9 Objects evaluate the LV diastolic dysfunction caused by functional and morphologic alterations of both RV and LV in patients with PAH, using Doppler and 2DSTI quantitatively. investigate whether or not the LV diastolic dysfunction using Doppler and 2DSTI is associated with the severity of cardiac function in patients with PAH.
10 Methods Study Patients Pulmonary arterial hypertension ( PAH): 50 patients mean age ; 44±10 years Healthy control subjects ( N) : 18 subjects mean age ; 40±9 years PAH has been defined as an increase in mean pulmonary arterial pressure 25mmHg at rest as assessed by right heart catheterization. All patients were in sinus rhythm, and had no left heart disease.
11 Methods Two Dimensional Transthoracic Echocardiography (2DE) Right ventricular end-diastolic area index (RVEDAI) Right ventricular end-systolic area index (RVESAI) RV fractional area change (%RVFAC) =100 (RVEDA ー RVESA)/RVEDA Left ventricular end-diastolic area index (LVEDAI) Left ventricular end-systolic area index (LVESAI) Left ventricular ejection fraction (LVEF) using Modified Simpson method TR jet pressure gradient by Doppler echocardiography the size of the inferior vena cava (IVC) and the changes in its size during respiration
12 Methods Echocardiography Artida (Toshiba Medical Systems) Transthoracic echocardiogram was performed using PST-30SBT probe. Two-dimensional transthoracic Echocardiography (2DE) Pulsed Doppler Imaging: mitral inflow Tissue Doppler Imaging: myocardial velocities of the mitral annulus 2D Speckle tracking imaging (2DSTI): longitudinal strain and strain rate 2D-Speckle-tracking analysis: 2D Wall Motion Tracking (Toshiba Medical Systems)
13 Methods Pulsed Doppler &Tissue Doppler Imaging The mitral annular motion velocity in lateral segment peak early diastolic myocardial velocity (e ) The mitral inflow velocity peak early diastolic mitral inflow velocity (E) peak late diastolic mitral inflow velocity (A) The isovolumic relaxation time (IRT) The deceleration time(dt) of early mitral inflow (E) E A s DT e a Pulsed Doppler mitral inflow image mitral annular motion velocity
14 Methods 2D Speckle Tracking Imaging Longitudinal Strain Rate Global LV Strain Rate LV free wall Strain Rate Global left ventricle (LV) longitudinal strain rate (SR) in the apical 4-chamber view were calculated with the use of the entire length of the LV myocardium. LV free wall is divided into three segments. LV free wall longitudinal SR in mid-ventricular segments of the LV free walls in the 4-chamber apical view was evaluated.
15 Methods LV Longitudinal Diastolic Strain Rate During IVR period and Early Diastolic Phase RSR AVC MVO LV EDSR RSR (relaxation strain rate ) :Peak relaxation SR during the IVR period LV EDSR (early diastolic SR) : Peak LV early diastolic SR during early diastolic phase AVC: aortic valve closure MVO: mitral valve opening LV free wall EDSR Global LV EDSR LV longitudinal strain rate curve Wang J. Circulation. 2007;115:
16 Methods Right Heart Catheterization All patients underwent right heart catheterization within the same day performed 2D echocardiography. Pulmonary artery pressure (PAP) Right atrial pressure (RAP) Pulmonary vascular resistance (PVR) Cardiac index (CI)
17 Results Patients Characteristics Characteristic PAH N P value Number Age (years) 44±10 40± Female(%) 40 (80%) 13 (72%) 0.07 Heart rate (b.p.m.) 81±17 66±10 <0.01 2DE data TR pressure gradient 79±26 22±10 <0.01 RVEDAI (cm/m 2 ) 20±5 11±2 <0.01 RVESAI (cm/m 2 ) 13±5 6±1 <0.01 %RVFAC (%) 31±1 45±4 <0.01 LVEDVI (ml/m 2 ) 29±11 49±6 <0.01 LVESVI (ml/m 2 ) 9±5 15±8 <0.01 LVEF (%) 70±7 67±6 0.12
18 Characteristic PAH N P value Doppler data E (cm/s) 55±19 83±19 <0.01 A (cm/s) 70±14 49±12 <0.01 E/A 0.8± ±0.3 <0.01 DT (ms) 180±40 138±25 <0.01 IRT (ms) 75±23 52±23 <0.01 e 8±3 14±3 <0.01 E/e 6.4± ± D speckle tracking LV free wall EDSR 1.10± ±0.64 <0.01 Global LV EDSR 0.98± ±0.48 <0.01 RSR 0.17± ±0.30 <0.01
19 Results Classification of PAH Patients using Appearance of Heart Failure PAH 50 patients PAH-HF 12 patients PAH-N 38 patients Patients with right heart failure (NYHA III or IV)
20 Results Patient Characteristics in Two PAH s Characteristic PAH-HF PAH-N P value number Age (years) 43±12 44± Female (%) 9 (75%) 30 (79%) 0.89 Heart rate (b.p.m.) 85±19 76± DE data RVEDAI (cm/m 2 ) 21±5 15±4 <0.01 RVESAI (cm/m 2 ) 17±6 11±4 <0.01 %RVFAC (%) 24±9 36±11 <0.01 LVEDVI (ml/m 2 ) 20±7 35±11 <0.01 LVESVI (ml/m 2 ) 5±2 11±5 <0.01 LVEF (%) 72±7 70± BNP 460±53 35±40 <0.01
21 Results Patient Characteristics in Two PAH s Characteristic PAH-HF PAH-N P value Systolic PAP by Doppler (mmhg) RV Catheter Data 90±27 74± Mean PAP (mmhg) 48±10 39±11 <0.01 Systolic PAP (mmhg) 83±16 65±19 <0.01 RVR 14.5± ±4.8 <0.01 RAP (mmhg) 11±8 6±3 <0.01 PCWP (mmhg) 8±3 9± CI (L/min/m2) 2.0± ±1.2 <0.01
22 Results Mitral Inflow Pulsed Doppler in PAH Patients (cm/s) 100 E P<0.001 E/A P<0.001 (ms) 300 DT P<0.001 (ms) 120 IRT P< ,2 60 0, , PAH-HF PAH-N 0 PAH-HF PAH-N 0 PAH-HF PAH-N 0 PAH-HF PAH-N
23 Results Mitral Anulus Tissue Doppler in PAH Patients 20 e' P< PAH-HF PAH-N
24 LV EDSR Global LV EDSR RSR Results LV Longitudinal Diastolic Strain Rate During IVR period & Early Diastolic Phase 2 LV free wall EDSR (s -1 ) P=0.007 (s -1 ) 2 Global LV EDSR P< ,4 (s -1 ) RSR P= , ,2 0,1 0 PAH-HF PAH-N 0 PAH-HF PAH-N 0 PAH-HF PAH-N
25 RSR RSR Results Correlation between RSR and BNP, Cardiac Index 0,5 0,4 (s -1 ) (s -1 ) R==0.450 R2=0.202 P= ,5 0,4 R==0.376 R2=0.141 P= ,3 0,3 0,2 0,2 0,1 0, CI BNP(LN)
26 Global LV EDSR Global LV EDSR Results Correlation between Global LV early diastolic SR and BNP, Cardiac Index 2,5 (s -1 ) (s -1 ) 2 R=0.389 R2=0.154 P= ,5 2 R= R2=0.201 P= ,5 1, ,5 0, CI BNP(LN)
27 LV EDSR LV EDSR Results 2,5 Correlation Between LV free wall EDSR and BNP, Cardiac Index (s -1 ) (s -1 ) 2 R=0.389 R2=0.154 P= ,5 2 R=0.354 R2=0.125 P= ,5 1, ,5 0, CI BNP(LN)
28 Conclusion The LV diastolic dysfunction ( abnormal LV relaxation and impaired LV filling) appeared in patients with PAH. Using 2DSTI, LV diastolic dysfunction was seen in the LV free wall and global LV wall, and the severity of heart failure in PAH increased according to LV diastolic dysfunction. The E, E/A, e, and LV longitudinal strain rate by 2DSTI are useful parameters for the noninvasive and quantitative assessment of LV diastolic dysfunction and the severity of cardiac dysfunction in patients with PAH.
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