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LETTERS TO THE EDITOR

Diagnosis of Diastolic Dysfunction: Importance of Spectral Doppler Imaging

Postoperative Cardiac Surgical Intensive Care Unit, Ghent University Hospital, Gent, Belgium

To the Editor:

I read with great interest the article of Bernard et al. (1) concerning the relationship between preoperatively assessed diastolic dysfunction and adverse outcome after cardiopulmonary bypass, with increased frequencies of inotropic support and delayed weaning. Although I agree completely with the authors’ conclusions stressing the routine inclusion of diastolic function parameters in each transesophageal echocardiography (TEE) investigation, I have some concerns about the interpretation of Doppler patterns in general with respect to diagnosis of diastolic dysfunction and the initial assessment of transmitral flow pattern, especially before the surgical procedure. It is well known that the early transmitral flow wave velocity (E) is strongly dependent on loading conditions. How was the influence of potent vasodilating anesthetic drugs excluded? Moreover, the indices of the pulmonary venous Doppler patterns are both sensitive to loading conditions and, in addition, depend also on compliance of both left atrial and left ventricular and elevated left ventricular filling pressures. What happens when totally different values of parameters from the left and right pulmonary venous patterns are found in left and right pulmonary veins? Hence, classifying patients in a subset "impaired relaxation" is at least difficult in this respect, without comparison with preoperative transmitral flow patterns of that same patient, and this is even more true when acute hemodynamic changes occur (e.g., during an operation, in the intensive care unit). Particularly in patients with a left ventricular fractional area contraction above 50%, it is clear that a E/A < 1 is seldom linked with impaired relaxation and should be interpreted primarily as a low filling state (often aggravated by "overmedication" with diuretics). In addition, important alterations in transmitral filling patterns may vary significantly within the same patient. A dynamic test, as recently proposed by De Hert et al. (2), is a more appealing technique to differentiate within and between patients with diastolic dysfunction. This technique, however, is not always appropriate and is sometimes dangerous. Several authors have therefore proposed some supplementary assessments to determine more accurately the presence of diastolic dysfunction.

TEE has the power to simply analyze contractility (3), preload and afterload (4) in an independent manner. In addition, a preload independent, noninvasive index of relaxation has been proposed. Tissue Doppler velocities may be shown either by color M-mode (5, 6), tissue Doppler imaging (TDI) (7,8) or two-dimensional mode. Whereas Doppler ultrasound has been traditionally utilized to measure flow velocities of red blood cells, TDI allows measurement of velocities of myocardial tissue (typically low velocities in conjunction with high amplitude) at certain points (9). TDI, which has a high reproducibility rate (10), has several advantages. First, determination of isovolumic relaxation and contraction time is much simpler to assess. Second, during tachycardia TDI remains useful with respect to assessment of diastolic function (11) in contrast to mitral inflow Doppler (because of fusion of the different flow waves). Finally, the relationship between mitral inflow and TDI can be used to estimate pulmonary capillary wedge pressure (12). Utilizing TDI in conjunction with routine Doppler parameters may hold a promising future in the noninvasive hemodynamic management of critically ill patients. Recognition of early filling wave with TDI in conjunction with the transmitral E may lead to a more easily interpretable assessment of diastolic function (Table 1)and be much more reliable, particularly when evaluating patients with concomitant valve disease.

1. Bernard F, Denault A, Babin D, et al. Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary bypass. Anesth Analg 2001; 92: 291–8.[Abstract/Free Full Text]
2. De Hert S, Vander Linden P, Ten Broecke P, et al. Assessment of length-dependent regulation of myocardial function in coronary surgery patients using transmitral flow velocity patterns. Anesthesiology 2000; 93: 374–81.[Web of Science][Medline]
3. Schmidt C, Roosens C, Struys M, et al. Contractility in humans after coronary artery surgery: echocardiographic assessment with preload-adjusted maximal power. Anesthesiology 1999; 91: 58–70.[Web of Science][Medline]
4. Brun P, Tribouilly C, Duvan A-M, et al. Left ventricular flow propagation during early filling is related to wall relaxation: a color M-mode Doppler analysis. J Am Coll Cardiol 1992; 20: 420–32.[Abstract]
5. Takatsuji H, Mikami T, Urasawa K, et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol 1996; 27: 365–71.[Abstract]
6. Sohn D-W, Chai I-H, Lee D-J, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997; 30: 474–80.[Abstract]
7. Oki T, Tabata T, Mishiro Y, et al. Pulsed tissue Doppler imaging of left ventricular systolic and diastolic wall motion velocities to evaluate differences between long and short axes in healthy subjects. J Am Soc Echocardiogr 1999; 12: 308–313.[Web of Science][Medline]
8. Trambaiolo P, Tonti G, Salustri A, et al. New insights into regional systolic and diastolic left ventricular function with tissue Doppler echocardiography: from qualitative analysis to a quantitative approach. J Am Coll Cardiol 2001; 14: 85–96.
9. Vinereanu D, Khokhar A, Fraser A. Reproducibility of pulsed wave tissue Doppler echocardiography. J Am Soc Echocardiogr 1999; 12: 492–9.[Web of Science][Medline]
10. Sohn D-W, Kim Y-J, Chun H-G, et al. Evaluation of left ventricular diastolic function when mitral E and A waves are completely fused: role of assessing mitral annulus velocity. J Am Soc Echocardiogr 1999; 12: 203–8.[Web of Science][Medline]
11. Nagueh S, Middleton K, Kopelen H, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997; 30: 1527–33.[Abstract]
12. Nagueh S, Mikati I, Kopelen H, et al. Doppler estimation of left ventricular filling pressure in sinus tachycardia: a new application of tissue Doppler imaging. Circulation 1998; 98: 1644–50.[Abstract/Free Full Text]

Response

Department of Anesthesia, Montreal Heart Institute, Montreal, PQ, Canada

In Response:

Dr. Poelaert’s comments are of great interest to us and we agree that Doppler pattern can be influenced by loading condition. This is particularly true for transmitral valve velocity pattern, but the pulmonary venous flow is also affected by other factors, including age, heart rate, cardiac output, left ventricular systolic function, and left atrial function (1). In our study, the diagnosis of diastolic dysfunction was based not only on the mitral valve inflow but also on the pulmonary vein velocity signal as suggested by the Canadian Consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography (2). The Doppler examination was performed, as we mentioned, "before pericardiotomy during a period of hemodynamic stability." We routinely evaluate both pulmonary veins and have rarely encountered significant velocity differences before cardiac surgery Doppler signal from the right and left pulmonary veins are similar unless the Doppler signal intensity is attenuated because of improper positioning. The Doppler signal from the pulmonary vein can vary with mechanical ventilation, as we published before (1), but the systolic to diastolic ratio stayed the same. Klein et al. (3) observed discrepancies in velocities in up to 24% of patients with significant mitral regurgitation but in their series, the pulmonary flow was still abnormal in both veins. The use of a loading test (4) was not published when we collected the data and the use of tissue Doppler (5–8) was not a modality available on our transesophageal echocardiographic system at the time of the study. Furthermore, they are not yet part of the Canadian Consensus, which we used in the evaluation of diastolic dysfunction (2). We do agree however that they provide complementary and useful information on the appreciation of diastolic function. Our cardiologist, who was familiar with the use of tissue Doppler, did evaluate the mitral annular displacement in a semiqualitative fashion and could predict and confirm the type of diastolic abnormality based on visual inspection. This mode of evaluation, which is frequently discussed among "diastologists," had not been formally validated at the time of the study, so we could not mention it in the methodology.

References

1. Girard F, Couture P, Boudreault D, et al. Estimation of the pulmonary capillary wedge pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow: influence of the respiratory cycle during mechanical ventilation. J Cardiothorac Vasc Anesth 1998; 12: 16–21.[Web of Science][Medline]
2. Rakowski H, Appleton C, Chan KL, et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography. J Am Soc Echocardiogr 1996; 9: 736–60.[Medline]
3. Klein AL, Obarski TP, Stewart WJ, et al. Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity. J Am Coll Cardiol 1991; 18: 518–26.[Abstract]
4. De Hert SG, Vander Linden PJ, ten Broecke PW, et al. Assessment of length-dependent regulation of myocardial function in coronary surgery patients using transmitral flow velocity patterns. Anesthesiology 2000; 93: 374–81.
5. Takatsuji H, Mikami T, Urasawa K, et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol 1996; 27: 365–71.
6. Sohn DW, Chai IH, Lee DJ, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997; 30: 474–80.
7. Oki T, Tabata T, Mishiro Y, et al Pulsed tissue. Doppler imaging of left ventricular systolic and diastolic wall motion velocities to evaluate differences between long and short axes in healthy subjects. J Am Soc Echocardiogr 1999; 12: 308–13.
8. Trambaiolo P, Tonti G, Salustri A, et al. New insights into regional systolic and diastolic left ventricular function with tissue Doppler echocardiography: from qualitative analysis to a quantitative approach. J Am Soc Echocardiogr 2001; 14: 85–96.[Web of Science][Medline]

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