|Year : 2019 | Volume
| Issue : 4 | Page : 165-171
Study of efficacy of tissue Doppler imaging in diagnosing systolic and diastolic dysfunction and comparison to the conventional methods of left ventricular function assessment in heart failure patients
Kalyan Kurapati, Krishna Mala Konda Reddy Parvathareddy, Ravi Srinivas, Praveen Nagula
Department of Cardiology, Osmania Medical College/Osmania General Hospital, Afzalgunj, Hyderabad, Telangana, India
|Date of Submission||30-Aug-2019|
|Date of Decision||12-Sep-2019|
|Date of Acceptance||11-Nov-2019|
|Date of Web Publication||11-Dec-2019|
Department of Cardiology, First Floor, QuliQutub Shah Building, Osmania General Hospital, Afzalgunj, Hyderabad - 500 012, Telangana
Source of Support: None, Conflict of Interest: None
Objective: The study aims to ascertain left ventricular (LV) mitral velocity, systolic Sa, and diastolic Ea measured by tissue Doppler imaging (TDI) and compare with conventional parameters of assessment of LV function in patients with heart failure (HF). Background: HF is a major cause of disability and morbidity all over the globe, and there are increasing trends in epidemic proportions shortly considering the early onset of cardiovascular disease. TDI is a noninvasive method to assess the LV dysfunction both systolic and diastolic. TDI can be helpful as a diagnostic, prognostic tool in patients with HF. Materials and Methods: A total of 100 cases (72 male and 28 female) admitted to Osmania General Hospital with symptoms and signs of HF were studied. All patients underwent echocardiography, and their LV function was assessed by TDI. Peak velocities during systole Sa, early diastole (Ea), and late diastole (Aa) were measured and compared with conventional LV systolic (LV ejection fraction [LVEF]) and LV diastolic Doppler echocardiography (E/A). Results: In patients with HF, TDI parameter Ea in the assessment of diastolic dysfunction (DD) was statistically significant when compared with conventional Doppler echocardiography 79% and 67% respectively in diagnosing diastolic dysfunction (P < 0.01). The TDI parameter “Sa” used for systolic dysfunction less significantly correlated with LVEF (66% vs. 89%). Conclusion: TDI parameter “Ea” was the most powerful predictor of LVDD when compared to “E/A” Doppler echocardiography. LVEF was a more powerful indicator of LV systolic dysfunction when compared to Sa of TDI. TDI “Ea” and “Sa” parameters can be helpful as diagnostic, prognostic markers in HF patients with low ejection and normal EF.
Keywords: Conventional Doppler echocardiography, left ventricular ejection fraction, tissue Doppler imaging
|How to cite this article:|
Kurapati K, Reddy Parvathareddy KM, Srinivas R, Nagula P. Study of efficacy of tissue Doppler imaging in diagnosing systolic and diastolic dysfunction and comparison to the conventional methods of left ventricular function assessment in heart failure patients. Heart India 2019;7:165-71
|How to cite this URL:|
Kurapati K, Reddy Parvathareddy KM, Srinivas R, Nagula P. Study of efficacy of tissue Doppler imaging in diagnosing systolic and diastolic dysfunction and comparison to the conventional methods of left ventricular function assessment in heart failure patients. Heart India [serial online] 2019 [cited 2020 Jan 23];7:165-71. Available from: http://www.heartindia.net/text.asp?2019/7/4/165/272665
| Introduction|| |
Tissue Doppler imaging (TDI) is a sensitive, noninvasive, echocardiographic technique that uses the Doppler principle to measure the velocity of tissue motion within the myocardium. It helps in the quantitative assessment of both global and regional functions of the myocardium. This technique helps in the detection of subclinical and clinical left ventricular (LV) systolic and diastolic dysfunction (DD) and timely identification of the risk factors.
Heart failure (HF) is a clinical syndrome that occurs in patients with an acquired abnormality of cardiac structure and function due to coronary artery disease (CAD), hypertension (HTN), cardiomyopathy, who develop a constellation of clinical symptoms of pulmonary congestion (dyspnea), decreased cardiac output (easy fatiguability). Systemic congestions (distended neck veins and pedal edema) that leads to frequent hospitalizations, poor quality of life, and a shorter life expectancy.,
Globally more than 20 million people are affected by HF leading to poor life quality and short life expectancy due to an increase in the incidence of CAD, HTN, and cardiomyopathy. The prevalence of the disease also increases with age, mainly over 65 years. Its incidence approaches 10/1000 population after 65 years of age.,
HF is broadly classified into two groups:
- HF due to decreased ejection fraction (EF) also called as systolic HF or HFREF
- HF due to abnormal relaxation, diastolic dysfunction, in which EF is preserved. It is also called as diastolic HF or HFPEF.
- HF due to abnormal relaxation, diastolic dysfunction, in which EF is preserved. It is also called as diastolic HF or HFPEF
- To compare the conventional color Doppler echocardiography with TDI in patients with low EF and normal EF HF.
| Clinical Applications of Tissue Doppler Imaging|| |
Assessment of left ventricular systolic function
Systolic myocardial predictor velocity (Sa) at the lateral mitral annulus is a measure of longitudinal systolic function, and the systolic component (S') of the mitral annulus measured by TDI correlates well with LVEF  and has been shown to be a good of clinical outcome in various cardiovascular disorders; cutoff of >8 cm/s had a sensitivity of 79% and a specificity of 88% in predicting normal global LV function.
A reduction in Sa velocity can be detected within 15 s of the onset of ischemia, and regional reductions in Sa are correlated with regional wall motion abnormalities. Incorporation of TDI measures of systolic function in exercise testing to assess for ischemia, viability, and the contractile reserve has been suggested  because peak Sa velocity normally increases with dobutamine infusion and exercise  and decreases with ischemia.
The peak systolic velocity is also a sensitive marker of mildly impaired LV systolic function, even in those with a normal LVEF or preserved LV systolic function, such as diastolic HF, or in diabetic patients without overt heart disease.
Nagueh et al. also demonstrated that load increases on average raised the transmitral E velocity by 70%, whereas the same manipulations produce only a 13% change in Ea. Therefore, low Ea values are indicative of abnormal LV relaxation even when LV filling pressure or increase.
Estimation of left ventricular filling pressures
Simultaneous cardiac catheterization and echocardiographic studies have shown that LV filling pressures are correlated with the ratio of the mitral inflow E wave to the tissue Doppler Ea wave (E/Ea). This relation is based on Ea velocities that “correct” E-wave velocities for the impact of relaxation. The E/Ea ratio can be used to estimate LV filling pressures as follows: E/lateral Ea >0 or E/septal Ea >15 is correlated with an elevated LV end-diastolic pressure and E/Ea <8 is correlated with a normal LV end-diastolic pressure.
Early diagnosis of genetic disease
Although unexplained LV hypertrophy is typically required to diagnose hypertrophic cardiomyopathy, the degree of hypertrophy and age of onset are highly variable. Abnormalities of diastolic function, as reflected by a reduction of Ea velocities, are present in individuals who have inherited a sarcomere gene mutation before the development of LV hypertrophy., Reduced Ea velocities have been similarly demonstrated in patients in the early stages of Fabry disease.
Differentiation between constrictive and restrictive physiologies
Both constrictive pericarditis and restrictive cardiomyopathy are associated with abnormal LV filling. With constrictive physiology, pericardial constraint impedes normal filling. In the absence of myocardial disease, Ea velocities typically remain normal. In contrast, the intrinsic myocardial abnormalities characteristic of restrictive cardiomyopathy result in impaired relaxation and reduced Ea velocities.
Assessment of cardiac dyssynchrony
Identifying patients who will benefit from cardiac resynchronization therapy, which can improve HF morbidity and mortality rates, has been challenging. TDI can be used to assess the relative timing of peak systolic contraction in multiple myocardial regions. The standard deviation (SD) of the time-to-peak contraction represents a measure of overall ventricular synchrony and may help identify potential responders to cardiac resynchronization therapy.
Assessment of right ventricular function
The complexity of right ventricular anatomy and geometry challenges an accurate assessment of right ventricular systolic function, an important prognostic indicator in patients with HF and postinfarction patients. Reduced tricuspid annular velocities with TDI have been documented in a variety of disease settings, including posterior inferior wall myocardial infarction (MI), chronic pulmonary HTN, and chronic HF (CHF).
Prognostic value of tissue Doppler imaging
TDI has a prognostic role in patients with congestive cardiac failure, myocardial infarction (MI) and hypertension (HTN). A Sa and Ea value of < 3 cm/sec has a very poor prognosis. A high mean S value in the basal segment of patients with suspected CAD is associated with lower mortality rate or MI and superior to wall motion score.
Yu et al. demonstrated the prognostic role of TDI-derived parameters in major cardiac events, such as heart failure, acute MI, and HTN. Myocardial mitral annular and basal segmental (Sm) systolic and early diastolic (Ea) velocities were shown to predict the mortality of cardiovascular events. A high mean Sm value in basal segments in patients with suspected CAD is associated with a lower mortality rate.
Paulus et al. demonstrated various strategies for the diagnosis and exclusion of heart failure with normal ejection fraction (HFNEF) by TDI, that are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.
De Sutter et al. conducted a study on 174 normal patients and 86 patients with HTN and LV hypertrophy to assess the effects of age, gender, and left ventricular hypertrophy on E' and E/E'. Age appeared to be the strongest determinant of E' and E/E', suggesting that in normal patients and those with LV hypertrophy, age-dependent cutoff values should be considered.
Acil et al. conducted the study in 132 CHF patients and concluded that mitral E/E' is a stronger predictor of future cardiac events than conventional echo parameters of systolic or diastolic or overall LV performance.
Kasner et al. compared various conventional Doppler and tissue Doppler echocardiographic index with pressure–volume loop analysis to assess their accuracy in detecting LVDD in patients with HF. The TDI indices were accurately correlated with the pressure volume loop analysis.
Ommen et al. in their study Showed DD is a major finding in contribution to the signs and symptoms of HF. They compared the invasive assessment of the filling pressures to the conventional doppler methods DT (deceleration time) and E/A ratio (early diastolic – E, atrial contraction phase – A) correlate with LV filling pressure when EF <50%.
Wang et al. observed that the TDI-derived parameters Sm, Em, Am are powerful predictor of cardiac mortality compared to clinical data and standard echocardiographic measurements. This easily available measurement adds significant value in clinical management as cardiac patients. An Em <3 cm/s, Am <4 cm/s, and E/Em >20 can identify patients at very high risk of cardiac death in the subsequent 2 years.
Oh et al. concluded that in patients with clinical evidence of HF, normal EF on two-dimensional (2D) echo immediately suggested the diagnosis of diastolic HF. TDI, color flow imaging, and myocardial tissue imaging can confirm/exclude the diagnosis of diastolic HF by assessing intrinsic diastolic function and estimating diastolic filling pressure.
Hamdan et al. conducted a study on 59 patients of CHF – New York Heart Association (NYHA) functional Class III and IV – and concluded that E/E' ratio was the best measurement for differentiating patients with functional Class III and IV, and it also correlated with cardiac mortality and hospitalization, thereby providing additional values to standard echo measure.
Nikitin et al. conducted a study to assess the prognostic value of various conventional and novel echocardiographic indices in patients with CHF caused by LV systolic dysfunction. One hundred and eighty-five patients with CHF and LVEF <45% despite pharmacological therapy were enrolled. Two dimensional echocardiography was done to assess global LV systolic function and the volumetric data of each patient was obtained. Systolic, early and late diastolic mitral annular velocities were measured with color-coded TDI. The final conclusion of the study was that the strongest and independent echocardiographic predictor of prognosis was systolic mitral annular velocity measured by TDI.
Wang et al. conducted a study on 518 participants and concluded that mitral annulus velocity measured by TDI in early diastole gives incremental predictive power for cardiac mortality when compared to clinical data and standard echographic measure.
| Materials and Methods|| |
This study was done in the inpatient and outpatient setting of the Department of Cardiology, Osmania General Hospital. Ethical committee approval for the study has been taken. It is a single-center cross-sectional study. The study was conducted from June 2017 to November 2018. All patients with cardiac complaints were examined and included in the study who were diagnosed to have HF as per the inclusion criteria. A total of 100 patients were enrolled in the study.
Patients with age >18 years, features of HF, and with a diagnosis of CAD, HTN, and cardiomyopathy were included.
Patients with chronic obstructive pulmonary disease, complete heart block, congenital heart disease, pericardial effusion, cardiac tamponade, anemia, rheumatic valvular heart disease, pulmonary thromboembolism, acute coronary syndrome and infective endocarditis, and liver disease were excluded.
Method of collection of data
A detailed history of all patients was taken at the time of admission from patients or their relatives. The points regarding the presenting complaints – onset, duration and progress were noted. The diagnosis of HF was based on the presenting complaints, clinical examination, and electrocardiogram, and in all patients, routine blood investigations such as hemoglobin, fasting lipid profile, and random blood sugar were done.
All patients were examined at rest in the left lateral decubitus position. The echocardiographic techniques and calculations of different cardiac dimensions and volumes were performed according to the recommendations of the American Society of Echocardiography. LVEF by 2D echocardiography was obtained by modified biplane Simpson's method from apical four-chamber views.
Conventional Doppler echocardiography
The mitral flow velocities were recorded with pulsed wave Doppler with the sample volume placed at the tip of the mitral valve leaflets from the apical four-chamber view. From the mitral inflow velocity curve, the following measurements were made: peak E-wave velocity and peak A-wave velocity.
TDI myocardial velocities were recorded using a standard pulse-wave Doppler technique, as previously described. The sample volume was at the junction of the LV wall with the mitral annulus of the lateral myocardial segments from the four-chamber view, and peak velocities during systole (Sa), early diastole (Ea), and late diastole (Aa) were measured.
SPSS software 21.0 version (Statistical Package for Social Sciences for Windows, Chicago, Ilinois, USA). was used for the evaluation of means and SD. Continuous variables are mentioned in mean and SDs. The proportion of means was evaluated by student t-test, and P < 0.05 was considered statistically significant.
Bar diagrams are used wherever necessary. Categorical variables are depicted as numbers.
| Results|| |
The total number of heart failure cases admitted was 100 in Osmania General Hospital. Of the 100 cases, 72 were male and 28 were female. The baseline characteristics of the study group are shown in [Table 1]. The LVEF, conventional doppler and TDI values of the patients with systolic and diastolic HF with p values for each are shown in [Table 2]. [Figure 1] shows the NYHA class at presentation, and [Figure 2] shows the risk factors of the group.
|Table 2: Conventional and tissue Doppler imaging values in the study group|
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|Figure 1: New York Heart Association class at presentation in the study group|
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The most common symptom at presentation was chest pain present in 54 patients, followed by dyspnea seen in 40 patients. Most of the patients were in NYHA Class III (36) and Class II (18) at presentation [Table 1] [Figure 1]. Most of the patients were hypertensive (79), followed by diabetes (59) [Figure 2].
The LVEF was normal in 11 patients (65.67 ± 8.30) versus reduced in 89 patients (38.19 ± 11.30, P < 0.0001). Systolic dysfunction by TDI was seen in 66 patients compared to normal in 34 patients (5.83 ± 1.74 vs. 9.40 ± 1.28, P < 0.0001). DD by TDI Ea < 8 was seen in 79 patients compared to normal in 21 patients (6.74 ± 2.88 vs. 9.87 ± 1.47, P < 0.0001). Diastolic function by conventional Doppler was normal in 43 patients compared to dysfunction in 67 patients (1.21 ± 0.8 vs. 1.89 ± 0.62) [Table 2].
The comparison of number of patients categorized as having normal or LV dysfunction (systolic and diastolic) between the conventional methods and TDI is shown in [Table 3].
|Table 3: Conventional and tissue Doppler imaging in assessing patients with systolic and diastolic dysfunction|
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| Discussion|| |
TDI uses Doppler principles to measure the velocity of myocardial tissue motion. Imaging of LV mitral annulus velocities provides a rapid assessment of LV systolic and diastolic function in long axis.
TDI peak LV systolic mitral annular velocity is known as Sa and TDI LV diastolic peak velocity is known as Ea. Conventional LV echo-Doppler parameters such as LV systolic function LVEF and LV diastolic Doppler function E/A were taken and compared with parameters of TDI.
Ashraf et al. conducted a study on 45 patients with HF, of which 13 patients were in Class IV, 9 patients were in Class III, and the rest were taken as controls. In our study, 36 were in Class III, whereas 18 were in Class IV, followed by 18 patients in Class I and 28 patients in Class II.
In our study, LV systolic function and diastolic function assessed by TDI (Sa and Ea waves respectively) were compared with conventional methods for assessment of LV function (LVEF and E/A) in patients with HF. In the present study, TDI value Ea for diastolic dysfunction (value < 8 cm/sec) was seen in 79 patients compared to conventional Doppler E/A (>1.5 for DD) seen in 67 patients. Twelve patients were categorized as having normal diastolic function which is statistically significant among the whole cohort ([Table 3], P < 0.01).
As the peak TDI Ea velocity reduces, there is increase in the severity of Left Ventricular diastolic dysfunction (LVDD). Sohn et al. have shown TDI peak Ea velocity is sensitive and specific technique than the conventional Doppler echocardiography in detecting LVDD.
TDI was an added advantage in detecting pseudonormalization over conventional LV diastolic Doppler. Nagueh et al., also demonstrated that –Ea‖ velocity less than (<8 cm) indicates impaired LV relaxation and can assist in differentiating a normal from a pseudonormal mitral inflow pattern. A limitation of TDI was angle dependency than other Doppler modalities.
LV systolic function assessment by TDI (Sa) (a value < 8 cm/sec indicates systolic dysfunction ) was seen in 66 patients compared to conventional LVEF < 50 seen in 89 patients. Twenty three patients were categorized as having normal systolic function by TDI which is statistically significant on comparison of proportion of means (p<0.01).
Bolognesi et al. had a smilar disparity between the TDI and conventional methods. They were compared with invasive methods of LV function assessment. TDI Ea correlated well with invasive assessment of diastolic function. When coming to systolic function assessment TDI Sa was not correlative with conventional methods.
TDI is an effective alternative method to assess the LV diastolic function than the LV systolic function. TDI early identifies the subset of patients being categorized as normal by conventional methods and thereby helps in preventing the complications of HF and early initiation of therapy.
The limitations of this study were as follows:
- Single-center study
- Interobserver and intraobserver variability not assessed
- Small number and follow-up of patients not done.
| Conclusion|| |
In the present study, males outnumbered females in HF.
- HTN emerges the most common risk factor in HF
- TDI Ea is a more specific technique in assessment of HFPEF than the conventional Doppler assessment (E/A)
- Conventional LVEF assessment was more reliable in detecting HFREF compared to the TDI Sa in the present study
- TDI may have an important role in the assessment of LV diastolic function than LV systolic function in HF
- TDI is an simple noninvasive alternative method to assess LV diastolic function. It has an added advantage in patients with pseudonormalization compared to conventional Doppler E/A value
Evaluation of TDI in larger proportion of patients and globally, with long term follow up will unveil the prognostic significance of TDI in patients with HF. Such trial evidence will help in formulation of new guidelines in HF and can have a great impact in early initiation of measures to reduce morbidity and mortality of the entity.
We acknowledge the staff of the cardiology department.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]