Determinants of LV diastolic function during atrial fibrillation: beat-to-beat analysis in acute dog experiments

Left ventricular (LV) diastolic function during atrial fibrillation (AF) remains poorly understood due to the complex interaction of factors and beat-to-beat variability. The purpose of the present study was to elucidate the physiological determinants of beat-to-beat changes in LV diastolic function during AF. The RR intervals preceding a given cardiac beat were measured from the right ventricular electrogram in 12 healthy open-chest mongrel dogs during AF. Doppler echocardiography and LV pressure and volume beat-to-beat analyses were performed. The LV filling time (FT) and early diastolic mitral inflow velocity-time integral ( Evti) were measured using the pulsed Doppler method. The LV end-diastolic volume (EDV), peak systolic LV pressure (LVP), minimum value of the first derivative of LV pressure curve (dP/d tmin), and the time constant of LV pressure decay (τ) were evaluated with the use of a conductance catheter for 100 consecutive cardiac cycles. Beat-to-beat analysis revealed a cascade of important causal relations. LV-FT showed a significant positive linear relationship with Evti ( r = 0.87). Importantly, there was a significant positive linear relationship between the RR interval and LV-EDV in the same cardiac beat ( r = 0.53). Consequently, there was a positive linear relationship between LV-EDV and subsequent peak systolic LVP ( r = 0.82). Furthermore, there were significant positive linear and negative curvilinear relationships between peak systolic LVP and dP/d tmin ( r = 0.95) and τ ( r = –0.85), respectively, in the same cardiac beat. In addition, there was a significant negative curvilinear relationship between dP/d tmin and τ ( r = –0.86). We have concluded that the determinants of LV diastolic function in individual beats during AF depend strongly on the peak systolic LVP. This suggests that the major benefit of slower ventricular rate appears related to lengthening of LV filling interval, promoting subsequent higher peak systolic LVP and greater LV relaxation.

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One-Year Change in the H2FPEF Score After Catheter Ablation of Atrial Fibrillation in Patients With a Normal Left Ventricular Systolic Function

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.699364 ◽

2021 ◽

Vol 8 ◽

Author(s):

Min Kim ◽

Hee Tae Yu ◽

Tae-Hoon Kim ◽

Jae-Sun Uhm ◽

Boyoung Joung ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Diastolic Dysfunction ◽

Diastolic Function ◽

Systolic Function ◽

Left Ventricular ◽

One Year ◽

Lv Diastolic Dysfunction ◽

Fat Volume ◽

Lv Diastolic Function

Background: It is unclear whether atrial fibrillation (AF) catheter ablation (AFCA) improves the left ventricular (LV) diastolic function. We evaluated the 1-year change in the H2FPEF score, which reflects the degree of LV diastolic function, after AFCA among patients with a normal LV systolic function.Methods and Results: We included 1,471 patients (30.7% female, median age 60 years, paroxysmal-type AF 68.6%) who had available H2FPEF scores at baseline and at 1-year after AFCA to evaluate the 1-year change in the H2FPEF score (ΔH2FPEF score[1−yr]) after AFCA. Baseline high H2FPEF scores (≥6) were independently associated with the female sex, left atrium (LA) diameter, LV mass index, pericardial fat volume, and a low estimated glomerular filtration rate. One year after AFCA, decreased ΔH2FPEF scores[1−yr] were associated with baseline H2FPEF scores of ≥6 [OR, 4.19 (95% CI, 2.88–6.11), p < 0.001], no diabetes [OR, 0.60 (95% CI, 0.37–0.98), p = 0.04], and lower pericardial fat volume [OR, 0.99 (95% CI, 0.99–1.00), p = 0.003]. Increased ΔH2FPEF scores[1−yr] were associated with a baseline H2FPEF score of <6 [OR, 3.54 (95% CI, 2.08–6.04), p < 0.001] and sustained AF after a recurrence within 1 year [SustainAF[1−yr]; OR, 1.89 (95% CI, 1.01–3.54), p = 0.048]. Throughout a 56-month median follow-up, an increased ΔH2FPEF score[1−yr] resulted in a poorer rhythm outcome of AFCA (at 1 year, log-rank p = 0.003; long-term, log-rank p = 0.010).Conclusions: AFCA appears to improve LV diastolic dysfunction. However, SustainAF[1−yr] may contribute to worsening LV diastolic dysfunction, and it was shown by increased ΔH2FPEF scores[1−yr], which was independently associated with higher risk of AF recurrence rate after AFCA.Clinical Trial Registration:ClinicalTrials.gov Identifier: NCT02138695.

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Simple echocardiographic scoring system to estimate left ventricular filling pressure based on visual assessment of time sequence of mitral and tricuspid valve opening

European Heart Journal ◽

10.1093/ehjci/ehaa946.1010 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Murayama ◽

H Iwano ◽

S Tsujinaga ◽

H Nishino ◽

S Yokoyama ◽

...

Keyword(s):

Diastolic Function ◽

Tricuspid Valve ◽

Visual Assessment ◽

Left Ventricular ◽

Filling Pressure ◽

Cardiac Events ◽

Assist Device ◽

Device Implantation ◽

Valve Opening ◽

Lv Diastolic Function

Abstract Introduction In the presence of elevated left ventricular (LV) filling pressure, mitral valve (MV) becomes to open early and precedes tricuspid valve (TV) opening in early diastole. Accordingly, time-delay of right ventricular inflow relative to LV inflow assessed by dual Doppler system was recently reported as a parameter of LV filling pressure. We assumed that visually-assessed time-delay of TV relative to MV opening could be a simple and alternative marker of elevated LV filling pressure. Purpose This study aimed to elucidate the clinical usefulness of the 2-dimensional echocardiographic scoring system, Visual assessment of time-difference between Mitral and Tricuspid valve opening (VMT) score, in patients with heart failure (HF). Methods We analyzed 119 consecutive HF patients who underwent echocardiography and cardiac catheterization within a day. Elevated LV filling pressure was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. LV diastolic function was graded according to the ASE/EACVI recommendations. Time sequence of opening of MV and TV was visually assessed in the apical 4-chamber view and scored to 3 grades (0: TV opening first, 1: simultaneous, 2: MV opening first). When the inferior vena cava diameter was >21 mm and collapsed <20% during normal respiration, 1 point was added and VMT score was calculated as 4 grades from 0 to 3. We also investigated 113 patients without worsening HF at VMT scoring for cardiac events defined as worsening HF, LV assist device implantation, or cardiac death for 1 year after the echocardiography. Results VMT was scored as 0 in 20 patients, 1 in 50 patients, 2 in 37 patients, and 3 in 12 patients. PAWP was elevated in patients with VMT score of 2 and 3 (0: 10±5, 1: 12±4, 2: 22±8, 3: 28±4 mmHg, ANOVA P<0.001) (Figure). In overall patients, VMT≥2 predicted elevated PAWP with accuracy of 86%. When the accuracy was tested in patients with reduced (<40%, HFrEF) and preserved LV ejection fraction (≥40%) respectively, the accuracy was excellent in HFrEF (96% and 77%, respectively). Importantly, VMT≥2 also had good accuracy of 82% for elevated PAWP in 33 patients in whom recommendations usually cannot grade diastolic function due to monophasic LV inflow. In the sequential Cox models, the addition of VMT score to the model including the plasma brain natriuretic peptide (BNP) level and LV diastolic grading improved the predictive power for elevated PAWP (P<0.001). During the follow-up, 20 cardiac events were observed (6 worsening HF, 9 LV assist device implantation and 5 cardiac death). Kaplan-Meier analysis showed that the patients with VMT≥2 were at higher risk of cardiac events than those with VMT≤1 (log-rank test P<0.001) (Figure). Conclusions The VMT score was a simple and accurate marker of elevated LV filling pressure and has an incremental benefit over BNP and LV diastolic function grading. Moreover, it could be a novel prognostic marker in patients with HF. Figure 1 Funding Acknowledgement Type of funding source: None

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Left ventricular diastolic function after electrical cardioversion of atrial fibrillation

Heart ◽

10.1136/heart.87.4.379 ◽

2002 ◽

Vol 87 (4) ◽

pp. 379-380 ◽

Cited By ~ 3

Author(s):

H J Muntinga

Keyword(s):

Atrial Fibrillation ◽

Diastolic Function ◽

Left Ventricular Diastolic Function ◽

Left Ventricular ◽

Electrical Cardioversion ◽

Ventricular Diastolic Function

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Three Vessel Coronary Cameral Fistulae Associated with New Onset Atrial Fibrillation and Angina Pectoris

Case Reports in Vascular Medicine ◽

10.1155/2014/475325 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3

Author(s):

Murat Yuksel ◽

Abdulkadir Yildiz ◽

Mustafa Oylumlu ◽

Nihat Polat ◽

Halit Acet ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Artery ◽

Coronary Angiography ◽

Left Ventricle ◽

Coronary Arteries ◽

Diastolic Pressure ◽

Left Ventricular ◽

Ventricular Rate ◽

Fistula Formation ◽

New Onset

Coronary cameral fistulas are abnormal communications between a coronary artery and a heart chamber or a great vessel which are reported in less than 0.1% of patients undergoing diagnostic coronary angiography. All three major coronary arteries are even less frequently involved in fistula formation as it is the case in our patient. A 68-year-old woman was admitted to cardiology clinic with complaints of exertional dyspnea and angina for two years and a new onset palpitation. Standard 12-lead electrocardiogram revealed atrial fibrillation (AF) with a ventricular rate of 114 beat/minute and accompanying T wave abnormalities and minimal ST-depression on lateral derivations. Transthoracic echocardiographic examination was normal except for diastolic dysfunction, minimally mitral regurgitation, and mild to moderate enlargement of the left atrium. Sinus rhythm was achieved by medical cardioversion with amiodarone infusion. Coronary angiography revealed diffuse and multiple coronary-left ventricle fistulas originating from the distal segments of both left and right coronary arterial systems without any stenosis in epicardial coronary arteries. The patient’s symptoms resolved almost completely with medical therapy. High volume shunts via coronary artery to left ventricular microfistulas may lead to increased volume overload and subsequent increase in end-diastolic pressure of the left ventricle and may cause left atrial enlargement.

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Abstract 649: Increased Left Ventricular Filling Pressure is Associated with Left Atrial Thrombus in Patients with Atrial Fibrillation.

Circulation ◽

10.1161/circ.118.suppl_18.s_593-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Katsuomi Iwakura ◽

Hiroshi Ito ◽

Atsunori Okamura ◽

Yasushi Koyama ◽

Motoo Date ◽

...

Keyword(s):

Atrial Fibrillation ◽

Diastolic Function ◽

Left Atrial ◽

Multivariate Logistic Regression Analysis ◽

Left Ventricular ◽

Filling Pressure ◽

Diastolic Filling ◽

Ventricular Filling Pressure ◽

Lv Diastolic Dysfunction ◽

Ventricular Filling

Patients with atrial fibrillation (AF) are frequently associated with reduced left ventricular (LV) diastolic dysfunction. It is still unclear whether reduced diastolic function is associated with the risk of left atrial (LA) thrombus in AF. The ratio of transmitral E velocity to mitral annular velocity (e′) is an echocardiographic estimate of diastolic LV filling pressure even under AF rhythm. We investigated whether reduced LV diastolic function is associated with the risk of LA thrombus in AF patients, using E/e′ ratio as an index. We enrolled consecutive 405 patients with non-valvular, paroxysmal or chronic AF, who underwent both transthoracic- (TTE) and transesophagial echocardiography (TEE) examination within a month. We measured LA and LV dimensions, LV ejection fraction (%EF), wall thickness, E and e′ velocities on TTE, and determined E/e′ ratio. LA appendage thrombus was found in 33 patients (8.1%). Patients with LA thrombus showed lower e′ velocity (5.3±1.8 vs. 7.0±2.2 cm/s, p<.0001) and higher E/e′ ratio (17.2±9.2 vs. 11.5±5.9, p<.0001) than those without it. Using 12.4 as an optimal cutoff point, E/e′ predicted LA thrombus with 70% sensitivity and 70% specificity (AUC=0.72). Odds ratio for LA thrombus in patients in the highest quartile of E/e′ was 6.38 (3.06–13.9). Multivariate logistic regression analysis indicated that the highest quartiles of E/e′ ratio was an independent predictor of LA thrombus among echocardiographic parameters, along with LA dimension and %EF, whereas e′ was not. LA appendage flow velocity was significantly correlated with E/e′ ratio (p<.0001), implying that increased diastolic filling pressure could be associated with impaired blood flow within LA. Increased LV filling pressure increased the risk of LA thrombus in patients with AF, partially through impaired LA hemodynamics. E/e′ ratio on TTE could be useful for detecting high-risk patients for LA thrombus.

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Changes in Mitral Annular Ascent with Worsening Echocardiographic Parameters of Left Ventricular Diastolic Function

Scientifica ◽

10.1155/2016/6303815 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4

Author(s):

Paula M. Hernández Burgos ◽

Angel López-Candales

Keyword(s):

Ejection Fraction ◽

Diastolic Function ◽

Electromechanical Coupling ◽

Left Ventricular Diastolic Function ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Clinical Indication ◽

Ventricular Ejection Fraction ◽

Stage 1 ◽

Lv Diastolic Function

Background. While the mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement of left ventricular ejection fraction, less is known about the relative value of mitral annular ascent (MAa).Methods. Our database was queried for complete transthoracic echocardiograms performed for any clinical indication. Baseline echocardiographic measurements were compared to determine any correlation between MAa and traditional Echo-Doppler echocardiographic measures to characterize left ventricular diastolic dysfunction (LVDD).Results. Patients with normal LV diastolic function were younger (41±13years) than patients with LVDD (stage 1:61±13years; stage 2:57±14years; and stage 3:66±17years;p=0.156). LV ejection fraction decreased in patients with stage 2 LVDD (63±17%) and was further reduced in patients with stage 3 LVDD (28±21;p=0.003).Discussion. While a vigorous MAa excursion was seen in patients with stage 1 LVDD, MAa significantly decreased in stage 2 and stage 3 LVDD patients. Our results highlight the importance of atrioventricular coupling, as MAa motion seems to reflect changes in left atrial pressure. Additional studies are now required to better examine atrioventricular interactions and electromechanical coupling that might improve our assessment of LV diastolic function.

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Application of the current HFA-ESC consensus guidelines on diagnosis of heart failure with preserved ejection fraction to a population referred for echocardiography

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.038 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

K Liang ◽

R Hearse-Morgan ◽

S Fairbairn ◽

Y Ismail ◽

AK Nightingale

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Diastolic Function ◽

Global Longitudinal Strain ◽

Diagnostic Algorithm ◽

Left Ventricular ◽

Lv Function ◽

Preserved Ejection Fraction ◽

Consensus Guidelines

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The recent Heart Failure Association (HFA) of the European Society of Cardiology (ESC) consensus guidelines on diagnosis of heart failure with preserved ejection fraction (HFpEF) have developed a simple diagnostic algorithm for clinical use. PURPOSE To assess whether echocardiogram (echo) parameters needed to assess diastolic function are routinely collected in patients referred for assessment of heart failure symptoms. METHODS Retrospective analysis of echo referrals in January 2020 were assessed for parameters of diastolic function as per step 2 of the HF-PEFF diagnostic algorithm. Echo images and clinical reports were reviewed. Electronic records were utilised to obtain clinical history, blood results (NT-proBNP) and demographic data. RESULTS 1330 patients underwent an echo in our department during January 2020. 83 patients were referred with symptoms of heart failure without prior history of cardiac disease; 20 patients found to have impaired left ventricular (LV) function were excluded from analysis. Of the 63 patients with possible HFpEF, HF-PEFF score was low in 18, intermediate in 33 and high in 12. Median age was 68 years (range 32 to 97 years); 25% had a BMI >30. There was a high prevalence of hypertension (52%), diabetes (19%) and atrial fibrillation (40%) (cf. Table 1). Body surface area (BSA) was documented in 65% of echo reports. Most echo parameters were recorded with the exception of global longitudinal strain (GLS) and indexed LV mass (cf. image 1). NT-proBNP was recorded in only 20 patients (31.7%). 12 patients with an intermediate HF-PEFF score could have been re-categorised to a high score depending on GLS and NT-proBNP (which were not recorded). CONCLUSION More than three quarters of echoes acquired in our department obtained the relevant parameters to assess diastolic function. The addition of BSA, and inclusion of NT-proBNP, and GLS would have been additive to a third of ‘intermediate’ patients to determine definite HFpEF. Our study demonstrates that the current HFA-ESC diagnostic algorithm and HF-PEFF scoring system are easy to use, highly relevant and applicable to current clinical practice. Age >70 years 29 (46.0%) Obesity (BMI >30) 16 (25.4%) Diabetes 12 (19%) Hypertension 33 (52.4%) Atrial Fibrillation 25 (39.7%) ECG abnormalities 18 (28.5%) Table 1. Prevalence of Clinical Risk Factors Abstract Figure. Image 1. HFPEFF score & echo parameters

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Abstract 10878: Validation of Non-invasive Measures of Diastolic Function in Children: A Simultaneous Echocardiography and Conductance Catheterization Study

Circulation ◽

10.1161/circ.132.suppl_3.10878 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Shahryar M Chowdhury ◽

Ryan J Butts ◽

Anthony M Hlavacek ◽

Carolyn L Taylor ◽

Varsha M Bandisode ◽

...

Keyword(s):

Diastolic Function ◽

Diastolic Pressure ◽

Ductus Arteriosus ◽

Left Ventricular ◽

Balloon Occlusion ◽

Heart Catheterization ◽

Active Relaxation ◽

Non Invasive ◽

Stiffness Constant ◽

Lv Diastolic Function

Introduction: The accuracy of echocardiography in evaluating left ventricular (LV) diastolic function has not been validated in children. The objective of this study was to compare echocardiographic and gold-standard measures of LV diastolic function in children. Methods: Patients undergoing routine left heart catheterization were prospectively enrolled. Pressure-volume loops (PVL) were obtained via conductance catheters. The end-diastolic pressure-volume relationship was obtained via balloon occlusion of the vena cavae. PVL measures of diastolic function were divided into early active relaxation (the isovolumic relaxation time constant, tau), and ventricular stiffness (the chamber stiffness constant, β). End-diastolic pressure (EDP) was also recorded. Echocardiographic measures of diastolic function were derived from spectral Doppler, tissue Doppler, and 2D speckle-tracking. The relationships between PVL and echocardiographic measures were determined using Spearman’s correlation. Results: Of 24 patients, 18 patients were s/p heart transplant, 5 patients had a small patent ductus arteriosus or coronary fistula. Mean age was 9.1 ± 5.6 years. The median τ was 24.9 ms (IQR 22.8 - 28.4 ms), median β was 0.094 (IQR 0.035 - 0.154), and median EDP was 9 mmHg (IQR 8 - 13 mmHg). Statistically significant correlations between invasive and echocardiographic measures of diastolic function are reported in the Table. No echocardiographic measures correlated with β. Conclusion: Early diastolic echocardiographic measures correlate with tau and may accurately represent early active relaxation in children. Modest associations exist between echocardiographic measures and EDP. The use of these non-invasive measures in accurately assessing LV diastolic function appears promising in children. However, no echocardiographic measures correlate with chamber stiffness. The development of such measures merits further study.

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Abstract 13910: Importance of Non-invasive Estimates of Left Ventricular Filling Pressures in Critically Ill Patients

Circulation ◽

10.1161/circ.142.suppl_3.13910 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Abdelrahman M Ahmed ◽

Brandon Wiley ◽

Jacob C Jentzer ◽

Nandan S Anavekar ◽

Allan S Jaffe

Keyword(s):

Diastolic Dysfunction ◽

Diastolic Function ◽

Critically Ill ◽

Critically Ill Patients ◽

Troponin T ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Adverse Outcomes ◽

Icu Mortality ◽

Lv Diastolic Function

Introduction: The presence of cardiac dysfunction predicts adverse outcomes in the intensive care unit (ICU). We explored the relationship of cardiac injury and left ventricular (LV) systolic and diastolic dysfunction (LVDD) to outcomes in critically ill patients. Methods: This is a retrospective analysis of adult medical ICU admissions from May, 2018 through October 2019. Patients with elevated high-sensitivity troponin T (hs-cTnT) and an echocardiogram performed within 72 hours of admission were included. Patients were classified as having normal LV diastolic function, isolated LVDD, concomitant LV diastolic and systolic dysfunction (LVDDSD) or indeterminate LV diastolic function based on American Society of Echocardiography 2016 guidelines. LV systolic dysfunction was defined as an ejection fraction (EF) < 50%. Results: Overall, 222 patients were included. LVDD was seen in 123 patients (55.4%). Thirty patients (13.5%) were classified with indeterminate diastolic function and 56 normal diastolic function (25.2%). Of those with LVDD , 59.3% had LVDDSD while isolated LVDD was seen in 40.7%.Patients with LVDDSD had a higher median hs-cTnT at baseline compared to patients with isolated LVDD [102ng/L IQR (50-257) vs. 77 ng/L (33.5-166); p=0.047]. Medial e’ velocity and tricuspid valve systolic regurgitant velocity were often associated with LV systolic dysfunction (p=0.0172 and 0.0013, respectively). LVDDSD was associated with a longer length of stay than patients with isolated LVDD [2.9 (1.6-4.0) vs.1.8 (1.1-3.3); p-value 0.03].Twenty-nine patients died during their ICU stay (13%). Patients with LVDDSD had 9.6-fold higher odds of dying in the ICU than patients with isolated LVDD (p=0.0048). Reduced medial e’ velocity (OR 0.63, CI 0.4-1.0, p=0.0285) and increased E/e’ (OR 1.08, CI 1.01-1.15, p=0.0192) were associated with ICU mortality. The association between LVEF<50% and ICU mortality was less pronounced (OR 0.95, CI 0.01-0.98; p=0.0023). Conclusions: Concomitant LV systolic and diastolic dysfunction and measures of increased cardiac filling pressures are strong predictors of mortality.

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