Assessment of ascending aorta distensibility after successful coarctation repair by strain Doppler echocardiography

BACKGROUND: Increased arterial stiffness may participate in the genesis of hypertension and increase of left ventricular (LV) mass after surgical correction of coarctation of the aorta. The purpose of the current study was to assess the aortic elastic properties using Doppler tissue imaging and strain rate imaging in patients after coarctoplasty. METHODS: Echocardiography with Doppler tissue/strain rate imaging capabilities was performed in 26 adult normotensive patients who had successful repair of coarctation of the aorta in infancy and in 24 control subjects. Transesophageal aortic transverse sections were imaged at the level of the proximal and distal segments to the repair site. Doppler tissue imaging wall velocities during systole (S(w)), early relaxation (E(w)), and atrial systole (A(w)) and peak systolic strain (ps epsilon) were measured in both groups. Transthoracic ascending aorta (AAo) measurements were also obtained. RESULTS: In the patients with coarctoplasty, S(w) velocities and ps epsilon were significantly decreased in the proximal segments compared with control subjects. Both peak systolic blood pressure after exercise (P < .001) and pulse pressure after exercise (P < .001) were directly related to AAo wall strain. LV annular early diastolic velocity was significantly reduced compared with control subjects in patients with decreased AAo wall strain and exercise-induced hypertension (P < .001) and related to AAo wall velocity (P < .005) and strain (P < .001). In multiple linear regression analysis, only weight, study group, and AAo wall strain were correlated to LV mass index. CONCLUSIONS: Patients with coarctation of the aorta have reduced proximal aortic wall velocities and strain and increased stiffness even after successful repair. This amplifies stress-induced hypertension and increases LV burden

Three-dimensional speckle tracking echocardiographic assessment of right ventricular function in chronic obstructive pulmonary disease with and without pulmonary hypertension.

Background: The purpose of this study was to assess right ventricular (RV) function in patients with chronic obstructive pulmonary disease (COPD) with and without pulmonary hypertension (PH) using three-dimensional speckle tracking echocardiography (3DSTE) and compare 3DSTE parameters with conventional RV function indexes. Methods: Thirty-two patients with COPD and thirty-two healthy subjects were studied. Twelve patients had PH confirmed by right heart catheterization (mean pulmonary artery pressure >25mmHg). Twenty patients had normal pulmonary artery pressures. Standard 2D measurements (tricuspid annulus excursion -TAPSE-, fractional area change -RVFAC-) and mitral and tricuspid tissue-Doppler annular velocities were obtained. RV 3D volumes, and RV global and regional ejection fraction (3DRVEF) were determined. Peak systolic velocities and strain were measured in the LV and RV free-wall segments. Respiratory function tests were performed (FEV1/VC = forced expiratory volume in one second / vital capacity; DLCO/VA = carbon monoxide diffusion lung capacity per unit of alveolar volume). Results: Global free-wall RV longitudinal strain (GFW-RVLS) and 3DRVEF were significantly lower compared to controls both in patients with PH (p<0.0001 and p=0.0003 respectively) and without PH (p<0.001 and p<0.005 respectively). Both GFW-RVLS and 3DRVEF correlated similarly with mean pulmonary artery pressure (r=0.62 and r=0.64; p=0.004 for both) and with pulmonary vascular resistance (r=0.65 and r=0.67; p=0.003 for both). No correlation was observed between RV and LV strain parameters. A significant relationship was shown between GFW-RVLS and DLCO/VA (r=0.72, p<0.005), and GFW-RVLS and FEV1/VC (r=0.75, p<0.001). Conclusions: RV 3D and 3DSTE parameters were abnormal in COPD patients compared to normals and had a higher association with COPD severity compared to standard RV function measurements. RV deformation changes did not appear to be a consequence of LV dysfunction. Detection of RV systolic impairment, even in the absence of pulmonary hypertension, suggests that RV myocardial damage in COPD cannot be blamed solely to pressure overload

Differentiation of pathologic forms of cardiac hypertrophy from athlete heart by 2D-strain-Doppler echocardiography

Purpose: Assessment of the underlying etiology of left ventricular hypertrophy (LVH) is a challenging clinical problem. In this study we sought to determine whether tissue Doppler imaging (TDI) and speckle tracking imaging (STI) could distinguish between subjects with pathological LVH, such as occurs in hypertensive heart disease, hypertrophic cardiomyopathy (HCM), or aortic stenosis, and those with athletic LVH. Methods: A total of 113 participants were studied, comprising competitive athletes (25), hypertensive heart disease (25), HCM (12), aortic stenosis (21), and healthy volunteers (30). Left ventricular mass index, ejection fraction, end-diastolic, end-systolic and stroke volume index, diastolic wall thickness, wall thickness ratio and diastolic and systolic wall-to-volume ratios were determined. Peak systolic longitudinal strain (e), peak systolic strain rate (SR-S), peak early diastolic strain rate (SR-E), and peak late diastolic strain rate (SR-A) values were measured by TDI in the basal, mid and apical segments in apical 4-chamber view. Averaged LV rotation and rotational velocities from the base and apex were obtained by STI and used for calculation of LV torsion (LVtor). The analysis of strain Doppler parameters and rotation was performed offline using customized computer software (EchoPac, Version 7.0, General Electric). All of the calculations were averaged for at least 3 consecutive beats. Results: Left ventricular (LV) mass indices were similar for all forms of LVH (p..05), which were higher than those obtained in healthy volunteers (p,.05). Athletes had no significant differences in e and SR-E compared with control subjects (p ¼ .16 and .82, respectively). Patients with pathologic LVH had significantly decreased e and SR-E (average septum: 216.8 + 3.2%, and 1.66 + 0.37 s-1, respectively) comparedwith control subjects (221.9 + 3.5%, and 2.44 + 0.45 s-1, respectively; all p,.0005). LVtor increased significantly in pathologic LVH and in athletes compared to normals (p,.005 and .0001, respectively). In pathologic LVH LVtor increased mainly as a result of reduced basal rotation (23.8+1.3 vs 26.1+1.6 degrees, p¼.04). In athletes the LVtor increase was the result of an increase in both basal and apical rotation (basal rotation, 26.1+1.6 vs 28.9+1.8 degrees, p¼.03; apical rotation, 17.2+3.2 vs 25.9+4.6 degrees, p¼.07). Conclusions: Pathologic LVH has significant longitudinal strain and SR-E reduction versus controls and a different pattern of LV torsion compared to athletes. These findings suggest that TDI and STI may have a clinical impact in the assessment of physiologic LVH state

Ascending aorta wall distensibility in healthy and hypertensive subjects: assessment by tissue Doppler velocity imaging

Purpose: The stiffening of aorta and other central arteries is a potential risk factor for increased cardiovascular morbidity and mortality. The purpose of this study was to investigate the potential clinical application of tissue Doppler imaging (TDI) for motion measurement of the aortic wall in healthy and hypertensive adults. Methods: We examined 31 hypertensive without a history of coronary artery disease (negative echo-stress test) and 31 age- and sex-matched healthy adults. Arterial pressure was measured with a mercury sphygmomanometer before echocardiography was performed. Pulse wave velocity (PWV) was measured as a standard parameter of arterial stiffness by oscillometric pulse wave analysis system (TensioMed Arteriograph, Hungary). Aortic M-mode and TDI parameters were measured 3 cm above the aortic valve. Aortic distensibility and aortic stiffness index (SI) were calculated using accepted formulae. Maximum velocity of the first and second systolic wall expansion peaks (S, S1,cm/sec), acceleration time (AT, msec), maximum velocity of early (E, cm/sec) and late (L, cm/sec) diastolic retraction velocity peaks of the ascending aorta and wall peak systolic strain (ps-e, %) were determined (EchoPAC, version 7.0, GE Ultrasound). Results: Observational variability was low. In hypertensive patients wall motion waveform showed lacking L, mixed S and S1 peaks, and blunted S compared with controls. S, E and ps-e were significantly lower in hypertensive than in healthy subjects. Reduced PWV and increased SI indicated increased aortic stiffness in both male and female hypertensive subjects. Age, diastolic blood pressure and sex were significant independent factors modulating S, while diastolic blood pressure and age were significant independent factors modulating E. PWV decreased with increasing age or systolic blood pressure. Duration of hypertension correlated with SI (r¼0.57, p,0.005), distensibility (r¼20.54, p,0.005) and S velocity (r¼20.62, p,0.001). There was a negative correlation between aortic stiffness and S velocity (r¼20.51, p,0.005). Multiple stepwise linear regression analysis in the hypertension group revealed that aortic S velocity (b¼0.35, p¼0.006), ps-e (b¼0.38, p¼0.007) and duration of hypertension (b¼20.51, p¼0.001) were the main predictors of aortic distensibility (overall R2 ¼ 0.53). Conclusions: Our data show that TDI measurement of ascending aortic wall motion provides qualitative and quantitative wall motion features differentiating hypertensive from healthy adults and reflecting aortic compliance changes related to age and sex

Strain Rate echocardiographic assessment of right ventricular performance in pulmonary arterial hypertension

Purpose: Pulmonary arterial hypertension (PAH) related to different aetiologies (chronic obstructive pulmonary disease -COPD-, congenital heart disease -CHD-; scleroderma -SCL-) is associated with high morbidity and mortality, with the most common cause of death being decompensated right heart failure. Our purpose was to compare tissue Doppler imaging (TDI) and strain rate imaging (SRI) parameters with conventional echocardiographic indexes evaluating right ventricular (RV) function, to assess their correlation with pulmonary artery pressure, and to investigate whether different PAH aetiologies could result in a different impact on RV performance. Methods: Forty-nine adult patients (pts) with PAH (SCL, 16 pts; COPD, 17 pts; CHD, 16 pts) were studied. All had systolic pulmonary artery pressure .35mmHg. Twenty-nine healthy subjects served as controls. RV ejection fraction (RVEF), fractional shortening (RVFS), and tricuspid flow filling parameters (E/A ratio, DT) were determined. Systodiastolic TDI values (Sw, Ew, Aw), peak systolic strain and systo-diastolic strain rate values were determined from RV free wall (RVFW) at 3 levels (basal, mid cavity, and apical) in the apical 4-chamber view. Results: Ew/Aw ratio and strain indexes were lower in pts than in controls (p,0.05 and p,0.001, respectively). There was a trend towards a higher incidence of lower RVEF, RVFS, E/A ratio, and DT in pts compared to controls. No correlation was found between RVEF, RVFS, E/A ratio, DT, and pulmonary artery pressure. A significant correlation was shown between mean peak systolic strain rate at RVFW site and pulmonary artery systolic pressure (r¼0.72, p,0.005). Significant decrease in systolic strain rate was obtained at apical FW site in COPD pts (p,0.005), at apical and mid level in CHD pts (p,0.001), and at basal, mid cavity, and apical levels in SCL pts (p,0.001). Conclusions: In PAH TDI/SRI parameters can determine RV dysfunction that may not be shown by conventional echo indexes and is correlated with severity of pulmonary artery pressure. Different forms of PAH can differently affect ventricular deformation parameters

Assessment of constrictive pericarditis by Tissue Doppler Imaging and Speckle Tracking Imaging

Purpose. Constrictive pericarditis (CP) is defined by a thickened, adherent, or calcific pericardium that limits myocardial free wall motion. Although normal or exaggerated early diastolic mitral annular velocity provides high specificity for differentiating CP from restrictive cardiomyopathy (RCM), its sensitivity has been shown to be lower. Our purpose was to assess the incremental value of Tissue Doppler Imaging (TDI) and Speckle Tracking Imaging (STI) for differentiation between CP and RCM. Methods. Eleven patients with CP, 8 with RCM, and 12 control subjects were studied. Standard mitral inflow Doppler and tissue Doppler echocardiography were performed. LV TDI annular peak systolic and diastolic velocities (S’, E’) and time difference between onset of mitral inflow and onset of E' (E'-E time) were measured. LV peak systolic longitudinal strain (l) and systolic and diastolic strain rate were obtained in the basal, mid and apical segments of septal and lateral walls in apical 4-chamber view both by TDI and STI. Transverse strain and averaged LV rotation and rotational velocities from the base and apex were also obtained by STI. Results. E' and S' were significantly higher in patients with CP than RCM (8.9 ± 1.5 vs 4.3 ± 1.4 cm/s, and 7.9 ± 1.1 vs 4.3 ± 1.6 cm/s respectively, p < .001). E'-E was significantly shorter in patients with CP (25.6 ± 21.7 vs 56.6 ± 24.7 ms, p < .005). Impairment of longitudinal strain in the lateral wall was shown (25.6 ± 16.7 vs 56.6 ± 21.3%, p < .005) whereas transverse strain values did not change significantly. ROC curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for detection of CP were -20% for STI-l (AUC 0.86), -23% for TDI-l (AUC 0.81), 32.6 ms for E’-E time (AUC 0.77), and -5.0 cm/sec for TDI-E’ velocity (AUC 0.73). Conclusions. TDI and STI parameters can be helpful to differentiate between CP and RCM by providing incremental diagnostic information to conventional Doppler echocardiography

Right ventricular performance in Ebstein’s disease by transesophageal strain Doppler echocardiography: A morpho-functional study in adult patients

Background: Ebstein’s anomaly of the tricuspid valve is a complex and fascinating congenital heart defect characterized by a spectrum of anatomical abnormalities that also involve the right atrium and right ventricle. The purpose of the present study was to assess right ventricular function using tissue Doppler imaging (TDI) and strain echocardiography in Ebstein’s patients (pts) to better understand the relationship between functional severity and anatomic derangement. Methods: Transesophageal echocardiography with TDI and strain capabilities (Aplio, Toshiba corp, Tokyo, Japan) was performed in 9 pts aged 12-39 years. 10 age- and sex-matched subjects with no signs of heart disease were selected as normal controls (CTR). Right ventricular ejection fraction (EF), fractional shortening (FS), and tricuspid flow filling parameters (E/A ratio, DT) were determined. Offline analysis of the myocardial velocity data sets was performed using dedicated software. Velocity and strain traces from right ventricular free wall were processed in the esophageal 4-chamber view. Systolic and diastolic TDI values (Sw, Ew, Aw), peak systolic strain and systolic and diastolic strain rate values were determined. Results: Measurements of TDI/SR parameters were rapidly obtained with a low inter- and intra-observer variability. Ew/Aw ratio was significantly reduced in pts compared to CTR (p<0.005). Peak systolic strain and systolic and diastolic strain rate at apical and mid level were also lower in pts than in CTR (p<0.001). Right ventricular EF, FS, E/A ratio, and DT were not significantly different among the two groups. No correlation was found between EF, FS, E/A ratio, DT, and anatomic derangement. A significant relationship was shown between peak systolic strain and apical displacement of septal/posterior leaflet (r=-0.67, p<0.001) and between peak systolic strain and the ratio of proximal to distal right ventricle (r=-0.72, p<0.001). Conclusion: Thus, Ebstein’s pts may present with systo-diastolic ventricular dysfunction that can be early assessed by strain Doppler echocardiography. This may lead to better decision-making regarding the indications for and timing of surgery

TDI-STI-based dobutamine stress echocardiography and Doppler-derived coronary flow reserve in ischemic heart disease

Purpose. The aim of this study was to evaluate whether assessment of coronary flow velocity (CFV) and coronary flow reserve (CFR) in left anterior descending coronary artery (LAD) by transthoracic Doppler echocardiography (TTDE) adds diagnostic information to both conventional 2D and strain-based dobutamine stress echocardiography (DSE). Methods. Forty-five patients underwent DSE and subsequent coronary angiography. Regional WMSI in the LAD territory was determined at baseline and at peak stress in each patient. Systolic (Sw), early (Ew) and late (Aw) diastolic myocardial velocities and strain rate (SR) and strain (e) parameters were obtained at rest and during low and peak dobutamine doses in apical 4-chamber, 3-chamber and 2-chamber views by Tissue Doppler Imaging (TDI) and Speckle Tracking Imaging (STI). CFR in the distal LAD was calculated as the ratio of mean diastolic velocity at peak dobutamine to baseline mean diastolic velocity. Results. CFV was successfully recorded in 41 patients (91%). Peak CFR was 2.2±0.9 in the study population and 3.3±0.6 in patients without LAD stenosis (p< 0.001). Sensitivity and specificity of abnormal CFR (< 2) to detect LAD stenosis were 88% and 66%, respectively. WMSI had a sensitivity and specificity of 63% and 87%. TDI and STI strain parameters had a sensitivity and specificity of 72% and 88% and 74% and 89%, respectively. In a regression multivariate analysis an abnormal CFR provided independent information compared to WMSI and SR (χ2 Model=33.17, incremental p value=0.0002). Conclusions. Abnormal CFR by TTDE adds diagnostic value to both conventional 2D and strain-based dobutamine stress echocardiography in detecting myocardial ischemi