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European Journal of Heart Failure 2000 2(2):151-160; doi:10.1016/S1388-9842(00)00075-1
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© 2000 European Society of Cardiology

Doppler tissue imaging in congestive heart failure patients due to diastolic or systolic dysfunction: a comparison with Doppler echocardiography and the atrio-ventricular plane displacement technique

Christina Jarnert*, Märit Mejhert, Margareta Ring, Hans Persson and Magnus Edner

Division of Internal Medicine, Karolinska Institute and Danderyds Hospital S-18288 Danderyd, Sweden

* Corresponding author. Tel.: +46-8-6556404; fax: +46-8-6226810.


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Background: Doppler tissue imaging (DTI) is an echocardiographic technique by which regional contractility, relaxation properties and time intervals are obtained easily. DTI has been reported to be relatively pre-load independent and could, in comparison with the commonly used mitral pulse wave Doppler (MPWD) method, be of clinical interest for identification of patients with diastolic dysfunction. The atrio-ventricular plane displacement (AVPD) method is an established technique to assess left ventricular systolic function.

Aims: To determine the pulsed Doppler DTI-pattern in patients with heart failure and to examine whether it has a similar capacity as MPWD and AVPD to diagnose diastolic dysfunction.

Methods: We studied 15 controls without congestive heart failure (CHF), 15 patients with diastolic (EF > 45% + CHF) and 15 patients with systolic (EF < 35% + CHF) left ventricular dysfunction and CHF.

Results: The DTI maximal velocities during systole (s), early filling wave (e) and atrial filling wave (a), decrease with reduced left ventricular ejection fraction, r = 0.75, r = 0.56 and r = 0.66 (P < 0.001) and regional isovolumetric contraction and intraventricular relaxation time measured by DTI are prolonged, r = 0.59 and r = 0.73, respectively (P < 0.001). The 15 patients with diastolic heart failure were identified by MPWD or DTI but only 11 by AVPD with 8, 10 and 9 false-positive, respectively (P < 0.01, P < 0.05 and NS).

Conclusions: Regional DTI show a consistent pattern in patients with left ventricular dysfunction and heart failure. Regional DTI has similar accuracy as MPWD in identifying diastolic heart failure patients and is superior to the AVPD technique. DTI may be a useful diagnostic tool in diastolic heart failure patients.

Key Words: Doppler tissue imaging • Heart failure

Received June 28, 1999; Revised February 17, 2000; Accepted March 6, 2000


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Doppler tissue imaging (DTI) is a recently developed echocardiographic technique in which the Doppler principle has been applied to assess several indices of myocardial function [1]. It allows simultaneous estimation of both systolic function and time intervals regionally in the myocardium [2]. The DTI mitral annular maximal velocity corresponds well with the left ventricular ejection fraction measured by radionuclide angiography [3–5]. DTI has also been reported to be relatively pre-load independent [6–8], which is of special interest in the diagnosing of mild systolic left ventricular dysfunction or in diastolic heart failure when the systolic left ventricular function is preserved. The method for assessment of diastolic function commonly used today, mitral pulse wave Doppler flow (MPWD), is well known to be influenced by several variables, for example filling pressures [9,10]. In order to find objective evidence of heart failure in such patients, methods which can improve our diagnostic possibilities are warranted [11,12].

Since diastolic left ventricular dysfunction is considered responsible for 30–50% of heart failure in older patients it is clinically relevant to determine if DTI is a useful method in these patients [13,14].

The atrio-ventricular plane displacement (AVPD) method has been shown to be a reliable and simple technique to study left ventricular systolic function in heart failure patients because the mitral annulus can be visualized in almost all patients even if the endocardial boarders are difficult to trace [15]. The AVPD method also has been reported to assess diastolic left ventricular function [16,17].

The aims of the study are: (1) to identify the DTI pattern in healthy controls and in patients with diastolic or systolic left ventricular dysfunction due to congestive heart failure (CHF); (2) to compare the DTI method with conventional Doppler echocardiography, i.e. MPWD flow and the AVPD technique; (3) to examine the potential of DTI to identify patients with mild systolic left ventricular dysfunction or diastolic heart failure compared with conventional echocardiography; (4) to describe the clinical characteristics in a patient group with diastolic heart failure compared with controls and systolic heart failure.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
2.1. Study population
In all, 45 patients were studied. Fifteen age-matched healthy subjects without clinical and electrocardiographic evidence of cardiovascular disease were recruited as controls (group C). Fifteen patients who were admitted to the hospital because of clinical signs of heart failure in which left ventricular ejection fraction was >45% were included in the diastolic heart failure group (DHF). Other possible explanations to the symptoms were excluded by blood chemistry, X-ray, and in some cases spirometry. Fifteen patients admitted to the hospital because of clinical signs of heart failure in which left ventricular function was <35% were included in the systolic heart failure group (SHF).

All patients were in sinus rhythm. There were no statistically significant group differences related to age, gender, heart rate or blood pressure.

The study was approved by the committee on ethics of the Danderyds Hospital. The nature and the purpose of the investigation were explained to the subjects, who gave their informed consent. The investigation conformed with the principles outlined in the Declaration of Helsinki. Baseline characteristics are presented in Table 1. In the diastolic group three patients had a history of prior MI, two Q-wave MI. Nine of the patients in the systolic group had a prior MI, five Q-wave MI. The region of the DTI registration was not directly involved.


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  		Table 1 Baseline characteristics of the patients in the studya

 
2.2. Echocardiographic measurements
All measurements were performed with the patient in the left semilateral position after stabilization of clinical symptoms, 7 days after the patient was admitted to the hospital. The ultrasound equipment used was Acuson 128 XP/10 (Mountain view, CA, USA) with a 2.5–4.0 MHz (V4c) probe. All recordings were stored on videotapes and analysed at the end of the study. Basic measurements of left ventricular dimensions in diastole and systole, thickness of intraventricular septum and posterior wall were measured by the M-mode technique. The left ventricular volumes and ejection fraction were measured according to the recommendations of the American Society of Echocardiography [18]. Biplane volumes were calculated from area tracings using the disc-summation method (modified Simpson’s rule). Ejection fractions were calculated as (diastolic–systolic)/(diastolic) volumes using dedicated computer equipment and software (TomTec Imaging Systems Inc., CO, USA).

Conventional echocardiography MPWD flow was measured by placing the sampling volume between the tips of the open mitral leaflets in the apical four-chamber view. Early (E) and atrial (A) transmitral maximal flow velocities, the ratio (E/A) and deceleration time (E-DT) of E was registered. Intraventricular relaxation time (IVR) was measured by the continuous wave Doppler technique. Pulmonary veins flow velocities during systole and diastole were measured approximately 5 mm proximal to the left atrium orifice. In this group with elderly patients, diastolic dysfunction is common but if the finding is not combined with heart failure signs it is called false-positive in this study.

Pulsed Doppler DTI was performed with the 4-mm sampling volume in the middle of the intraventricular septum 5–10 mm below the mitral annulus in the apical four-chamber view. This sampling point was chosen because the Doppler beam easily parallels the septal movement. The maximal velocity during systole (s), the duration of the movement during systole (s-dur), the regional intraventricular relaxation time (ivr), the maximal velocity during early filling phase (e) and atrial contraction filling phase (a), the deceleration time of the e-wave (e-dt) and the regional isovolumetric contraction time (ivc) were registered (Fig. 1).


Figure 1
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  		Fig. 1 Pulsed DTI profile illustrating: a, maximal velocity during atrial filling phase; e, maximal velocity during early filling phase; ECG, electrocardiogram; e-DT, deceleration time from top of e to baseline; ivc, regional isovolumetric contraction time; ivr, regional intraventricular relaxation time; PCG, phonocardiogram; s, maximal velocity during systolic contraction; s-dur, duration of systolic movement.

 
The AVPD towards and away from the cardiac apex was calculated by M-mode echo from an apical window. The septal and lateral AVPD was measured in the four-chamber view and anterior and posterior AVPD in the two-chamber view. The total AVPD was measured from the lowest to the highest point of contraction. A mean value of the AVPD (AV-mean) expressed in mm was calculated from the above four sites [19]. The contribution of AVPD during late diastole (AV-A) was calculated from the ratio of the magnitude of motion due to atrial systole to the total AVPD (AV-A/AV-mean) [16] (Fig. 2). All measurements were performed on three consecutive beats and the mean values are given.


Figure 2
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  		Fig. 2 AVPD recorded by M-mode echocardiography illustrating the total (T) movement during systole and during atrial contraction (A).

 
2.3. Statistical analysis
All given values are means±S.D. unless otherwise stated. Analysis of variance (ANOVA) was used to test for group differences. Categorical data were analysed using the two-tailed Fisher’s Exact test. All tests were performed at the ({alpha}2=0.05 level. A P-value<0.05 was considered significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
3.1. Basic echocardiographic parameters
Left ventricular end diastolic and end systolic dimensions and wall thickness expressed in millimetres and end diastolic and end systolic volumes in millilitres as well as ejection fraction in the three groups are listed in Table 2. There were no statistically significant differences between the controls and the patients in the diastolic heart failure group whereas the left ventricles in the systolic heart failure group were dilated and had depressed ejection fraction.


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  		Table 2 Basic echocardiographic parametersa

 
3.2. MPWD
The figures are given in Table 3. The E-DT was the single parameter which was statistically significantly different between controls and patients with diastolic heart failure. The maximal velocity of the atrial filling wave was lower in patients with systolic heart failure, and the pulmonary vein systolic/diastolic ratio was lower in these patients.


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  		Table 3 MPWD, DTI and AVPD in Controls (group C, n=15), patients with DHF (group DHF, n=15) and SHF (group SHF, n=15)a

 
3.3. DTI
The figures are given in Table 3. The duration of the systolic contraction time was statistically shorter in diastolic heart failure patients compared with controls and still shorter in the systolic heart failure group. The maximal velocity during atrial filling phase was lower and the isovolumetric contraction time longer in diastolic heart failure patients compared with controls. All parameters except for the e/a ratio were statistically significantly different in the systolic heart failure group of patients in comparison with controls and the diastolic heart failure group.

3.4. AVPD
All figures are given in Table 3. The mean value of the AVPD during both systole and diastole was statistically lower in the diastolic heart failure group compared with controls and it was still lower in the systolic heart failure group.

3.5. Identification of patients with diastolic heart failure
As demonstrated in Table 2, M-mode and two-dimensional echocardiography were not able to differentiate the controls from the patients with diastolic heart failure. The MPWD E/A ratio is perhaps the most commonly used parameter to assess diastolic dysfunction. The ratio decreases with age and in our patients it should be >0.7 which was used as a cut-off value in this patient group [20,21]. Ten of 15 patients in the diastolic heart failure group were correctly identified with four false-positive controls (NS) (Fig. 3). If an E-DT>260 ms or a E/A ratio<0.7 was used [22,23], 14 out of 15 patients in the diastolic heart failure group were identified with seven false-positive controls (P<0.05). If a low pulmonary vein flow systolic/diastolic ratio, <1.0 was taken into account, all 15 patients in the diastolic heart failure patient group were identified with eight false-positive controls (P<0.0 1) (Fig. 4).


Figure 3
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  		Fig. 3 Identification of DHF patients (Group DHF) in comparison with controls (Group C) by MPWD using a low E/A ratio (<0.7) (left), pulsed DTI a short s-duration (<302 ms) (middle) and AVPD a low AV-mean (<11.5 mm) (right).

 


Figure 4
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  		Fig. 4 Identification of DHF patients (Group DHF) in comparison with controls (Group C) by MPWD using a low E/A ratio (<0.7) or a long E-DT (>260 ms) or a low PV s/d (<1.0) (left), pulsed DTI a short s-duration (<302 ms) or a low maximal a velocity (<9.3 cm/s) or a long ivc (>70 ms) (middle) and AVPD a low AV-mean (<11.5) or a high AV-LA/AV-mean ratio (>51%) (right).

 
By pulsed Doppler DTI, if the s-duration was <302 ms nine of 15 patients with diastolic heart failure were identified with only two false-positive in the control group (P<0.05) (Fig. 3). If the s-duration or an isovolumetric contraction time>70 ms was used, 12 of 15 patients in the diastolic heart failure group were identified with five false-positive controls (P<0.05). If also the a maximal velocity, <9.3 cm/s was used as an indicator all 15 patients in the diastolic heart failure group were identified but with 10 false-positive controls (P<0.05) (Fig. 4). By the AVPD technique an AV-mean <11.5 mm identified 10 of the 15 patients in the diastolic heart failure group with five false-positive controls (NS) (Fig. 3). If the AV-mean<11.5 was combined with AV-A/AV-mean>51% 11 patients out of 15 were identified but this time with nine false-positive controls (NS) (Fig. 4).

One case from each group is shown in Fig. 5.


Figure 5
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  		Fig. 5 Recordings from a healthy control (left), a patient with DHF and a pseudo-normal pattern of the transmitral flow recording (middle) and a patient with SHF (right) illustrating MPWD, pulsed DTI and AVPD strips.

 
3.6. Covariation
The MPWD maximal A velocity was weakly related with ejection fraction, r=0.35 (P<0.05) and the E/A ratio was inversely correlated with ejection fraction, r=–0.36 (P<0.05). The PV s/d was weakly correlated with ejection fraction, r=0.42 (P<0.05). All the pulsed Doppler DTI parameters but the e/a ratio were correlated to ejection fraction, s-duration showing the strongest correlation, r=0.81 (P<0.001). The DTI ivr and ivc were inversely correlated to ejection fraction, r=–0.73 and r=–0.62, respectively (P<0.001). The e-DT measured by DTI was also correlated to ejection fraction, r=0.66 (P<0.001) and the E-DT obtained by MPWD turned out to be weakly inversely correlated to the ejection fraction, r=–0.35 (P<0.05). There was no correlation between these variables, indicating different causes. The AVPD AV-mean was statistically significantly correlated to ejection fraction, r=0.83 (P<0.00 1).

The heart rate (HR) was 65±10 (47–92) beats/min and both MWPD E/A and DTI e/a were correlated to HR, r=0.45 and 0.41 (P<0.01), respectively. E-DT was also correlated to HR, –0.37 (P<0.05) but not the DTI e-DT. The AVPD AV-mean and AV-A were both inversely correlated to HR, –0.41 and –0.47 (P<0.01), respectively.

3.7. Reproducibility
Reproducibility measurements were obtained in 10 subjects. The coefficient of variation for intra-observer analysis of left ventricular ejection fraction by modified Simpson’s rule was 3.4% and for the DTI parameters; s-max 2.5% s-dur 2.9%, e-max 1.9%, a-max 3.1%, e/a 2.0%, e-DT 2.8%, ivr 1.2% and ivc 1.9%.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The DTI technique makes it possible to obtain information on the regional left ventricle systolic and diastolic velocities as well as the time intervals during the cardiac cycle. It seems that there is a typical DTI pattern in the failing left ventricle which is characterized by decreasing velocities during both the systolic and the diastolic phase of the cardiac cycle. The prolongation of isovolumetric contraction and intraventricular relaxation time intervals which occur in left ventricular dysfunction can also be measured regionally. In patients with diastolic heart failure there are also signs of a mild systolic dysfunction by the DTI technique and the DTI technique appears to be as good as the commonly used MPWD technique to identify patients with diastolic heart failure but both techniques seem to be superior to the AVPD method in this group of patients.

Several studies have demonstrated that DTI measurement of maximal velocity during systole accurately reflect left ventricular systolic function [3–5]. However, in clinical practice methods used today to assess systolic left ventricular function, such as two-dimensional echocardiography ejection fraction by Simpson’s rule, wall motion scoring, eye-balling or the AVPD, are well known and understood and in this perspective the DTI method will probably not provide new advantages.

In the field of heart failure diagnostics there is a need for methods which can be properly used in patients with mild systolic or diastolic left ventricular dysfunction since this group of patients could be more difficult to identify, especially because of the pseudo-normalization phenomenon occurring in MPWD. Garcia et al. have suggested the maximal velocity during the early filling phase (the e wave) to be relatively pre-load independent [24]. This theory was confirmed in a study in which pre-load was increased by saline infusion or altered by nitroglycerine and the DTI e wave did not change but there were statistically significant changes in MPWD measured E wave [6]. The relative pre-load independence might explain why the DTI pattern shows a consistent pattern in patients with left ventricular dysfunction and heart failure with decreasing maximal velocities during systole (s), early filling wave (e) and atrial filling wave (a) and a prolongation of regional isovolumetric contraction and intraventricular relaxation time. This might also explain the decreasing e-DT by DTI in comparison with the increasing E-DT measured by MPWD. In some of our patients with heart failure and ejection fraction >45% there were evident changes in DTI parameters during the systolic as well as during the diastolic phase. The DTI technique therefore seems to be a useful diagnostic tool in patients with a very mild systolic or a diastolic left ventricular dysfunction.

Today, the most commonly used method to assess diastolic left ventricular dysfunction is the MPWD-technique which is a very sensitive method. The results are influenced by left atrial pressure and compliance, left ventricular pressure and compliance, the dynamic change in the mitral annulus area, heart rate and atrial contractility and age [23,25–28]. Normally, the first signs of a diastolic left ventricular dysfunction by means of MPWD is a lower E/A ratio and a prolongation of E-DT and IVR. If the patient improves, these parameters return to normal. Conversely, if the patient deteriorates, the parameters might also return to ‘normal’, the so-called pseudo-normalization phenomenon. Nitroglycerine or the Valsalva manoeuvre might be used to detect this situation. It is also recommended to register the pulmonary vein flow to disclose the pseudo-normalization phenomenon, but it is a time-consuming approach and cannot be done in all patients in clinical practice. If the patient gets still higher left ventricular filling pressures there will be a restrictive filling pattern of the left ventricle which is characterized by a high E/A ratio and a short E-DT and IVR.

In DTI, the information is obtained regionally from one single sampling point at a time, which is time saving. However, if the findings are normal in a patient with suspected heart failure it might be wise to examine additional segments of the ventricle.

The AVPD technique is a simple method in clinical practice since the mitral annulus can be visualized in almost all patients. It has been demonstrated that the AV-mean movement of the mitral annulus provides prognostic information in patients with heart failure [29]. However, in the group of patients with heart failure in which there is a normal systolic left ventricular function both the conventional MPWD and the new DTI technique appears to be superior.

In this study we used the clinical definition of diastolic heart failure, i.e. clinical signs of CHF but a normal systolic left ventricular function. We assessed the systolic function by two-dimensional echocardiography. However, the DTI indicated a systolic dysfunction expressed as a shorter s-duration time in the diastolic heart failure group compared with controls. Also the AVPD method indicated a systolic dysfunction with a lower AV-mean in the diastolic heart failure group compared with controls. This indicated the presence of a mild left ventricular systolic dysfunction in this group of patients. It has been suggested that diastolic heart failure might be combined with systolic dysfunction [30]. The patients in the DHF group are less symptomatic and have a better functional class expressed as NYHA-class compared with the patients in the SHF group. In the diastolic group three compared with nine patients in the systolic group had suffered a prior myocardial infarction. One of the advantages of DTI is the possibility to measure continuously during the heart cycle, and we found disturbances during the diastolic phase as well as during the systolic phase of the heart cycle. However, according to the MPWD results all patients in the DHF group showed signs of a left ventricular diastolic dysfunction.

4.1. Limitations of the study
We only examined elderly patients since the mean age of the heart failure patient is high. This makes the results useful in clinical practice but it is not yet known if the results are applicable for a younger patient group. All the patients in this study were in sinus rhythm but many heart failure patients are in atrial fibrillation and in this subgroup the DTI method is still not tested in comparison with conventional techniques. Our measurements are based upon only one region of the left ventricle and further information could have been obtained if other regions would have been included. The systolic left ventricular function was examined by two-dimensional echocardiography and further information would be gained by invasive measurements.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
DTI is a useful method in clinical practice and regional myocardial systolic and diastolic parameters as well as time-intervals are easily obtained by DTI. Further on, there seems to be a specific DTI pattern in heart failure and DTI show abnormal findings in patients with clinical CHF and normal systolic function. DTI seems to be a useful tool for diagnosing diastolic heart failure patients and has similar accuracy as the conventional echocardiography with MPWD flow. In patients with diastolic heart failure there are often signs of a mild left ventricular systolic dysfunction as well.


   Acknowledgements
 
This study was supported by the Karolinska Institute, Stockholm, Sweden.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC)
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Can natriuretic peptides be used for the diagnosis of diastolic heart failure?
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Diagnosing diastolic heart failure
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 Eur J Heart FailHome page
A. Kranidis and G. Filippatos
Letter to the Editor
Eur J Heart Fail, January 1, 2001; 3(1): 147 - 148.
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