Skip Navigation

European Journal of Echocardiography 2006 7(3):187-198; doi:10.1016/j.euje.2005.05.005
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Elnoamany, M. F.
Right arrow Articles by Abdelhameed, A. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Elnoamany, M. F.
Right arrow Articles by Abdelhameed, A. K.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © 2005, The European Society of Cardiology

Mitral annular motion as a surrogate for left ventricular function: Correlation with brain natriuretic peptide levels

Mohamed Fahmy Elnoamany* and Ayman Kilany Abdelhameed

Menofiya University, Egypt

Received 2 March 2005; accepted after revision 18 May 2005.

* Corresponding author. 11, Yossef Street from Talaat Harb Street, Shebin Elkom, Menofiya, Egypt. Tel.: +20 1066 13264; fax: +20 4823 25858. mnoamany{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Aim of the work
 Patients and methods
 Results
 Discussion
 Study limitations
 Conclusion
 References
 
Background Pulsed-wave (PW) Doppler tissue velocities of the mitral annulus correlate well with Left Ventricular (LV) diastolic(D) and systolic(S) functions. Brain natriuretic peptide (BNP) levels have been shown to be elevated in patients with symptomatic LV dysfunction (Dys) and correlate to the severity of symptoms and prognosis.

Objectives To validate the accuracy of mitral annular motion (MAM) assessed by Doppler Tissue Imaging (DTI) & M-mode Echocardiography (MME) as a surrogate for determination of LV function in comparison with BNP.

Methods A series of 133 patients with a variety of cardiac pathologies referred for echocardiography and 20 healthy age & sex matched volunteers as a control group were included the study. Ejection fraction (EF) of LV, Doppler recordings of the mitral inflow, MME and PWDTI data (from each of 4 mitral annular sites, inferior, anterior, septum and lateral) were obtained. Mean peak (S) MAM velocity (Sm), mean annular early (D) velocity (Em) by PWDTI and mean mitral annular plane (S) excursion (MAPSE) by MME were calculated by averaging of values measured at each annular site. BNP levels were measured by a rapid immunoassay and blinded to cardiologist making the assessment of LV function.

Results MAPSE < 12 mm determined by MME has 90% sensitivity, 88% specificity & 89% accuracy for detection of LVEF <50%, while these values were 94%, 93% & 94% respectively for (Sm) < 8 cm/s determined by PWDTI. BNP level >75 pg/ml has 98% sensitivity, 90% specificity & 97% accuracy for detection of LV Dys either (S,D, or both). BNP levels were significantly higher in patients with combined (S & D) Dys. Than those with only (S) Dys, the later group had significantly higher BNP levels than those with only (D) Dys. (1054.5 ± 202.3 pg/ml vs. 500 ± 39.9 pg/ml & 500 ± 39.9 pg/ml vs. 215.3 ± 100.9 pg/ml respectively, P < 0.001) & each were significantly higher than control group (12.3 ± 5.7 pg/ml, P < 0.001). Significant correlations (P < 0.001 for all) were found between BNP levels and Em (r =–0.82), Sm (r=–0.7), early transmitral (E) to Em ratio (r=0.61), MAPSE (r=–0.54), LVEF(r=–0.64) & LV end D dimension (r=0.63).

Conclusion MME and PWDTI used for assessment of MAM are useful methods for evaluation of LV function but parameters measured by PWDTI correlate more strongly with plasma BNP levels than those measured by MME and provide a simple, sensitive, accurate and reproducible tool for early diagnosis of LV dysfunction.

Keywords: Mitral Annular Motion; Doppler Tissue Imaging; Brain Natriuretic Peptide


   Introduction
Top
 Abstract
 Introduction
Aim of the work
 Patients and methods
 Results
 Discussion
 Study limitations
 Conclusion
 References
 
The mitral annulus is an essential, dynamic, and tightly coupled component of the mitral valve/left atrial/left ventricular complex that aids in effective and efficient valve closure and unimpeded left ventricular filling.1 The mitral annulus has a complex shape and motion, and its excursion has been correlated to LV function. During the cardiac cycle the annulus excursion encompasses a volume that is part of the total LV volume change during both filling and emptying.2 Although the dynamic nature of mitral annular motion has been studied carefully for more than 30years, accurate measurement of mitral annular area and motion continues to be a challenge for physiologists and clinicians alike. Roentgenographic cine imaging of radiopaque markers, sonomicrometry, magnetic resonance imaging, and two-dimensional echocardiography have all been used to evaluate mitral annular area and dynamics, yet widely disparate measurements abound.1

Longitudinal myocardial function has attracted interest in recent years. Impairment of long-axis left ventricular contraction and relaxation has been reported in experimental and clinical studies in the setting of coronary artery disease (CAD), myocardial infarction, LV hypertrophy (LVH), dilated cardiomyopathy, and hypertrophic cardiomyopathy.3

Doppler tissue imaging (DTI) is a recent echocardiographic technique that enables measurements of atrioventricular annular and regional myocardial velocities, and may be more sensitive than conventional echocardiography in detecting abnormalities of LV systolic and diastolic function.4–6 The method can be used to study both longitudinal and radial myocardial function. However, it is better suited for the assessment of long-axis ventricular shortening and lengthening because longitudinal motion has higher amplitude and is less affected by rotational and translational cardiac activity, making the velocities less prone to error and, therefore, more reproducible.7

B-natriuretic peptide (BNP) is a cardiac neurohormone secreted from the ventricles in response to ventricular volume expansion and pressure overload. BNP levels have been shown to be elevated in patients with symptomatic LV dysfunction and correlate to the severity of symptoms and prognosis. BNP levels may also reflect diastolic dysfunction. It has been shown that BNP is useful in establishing or excluding diagnosis of heart failure in patients with acute dyspnea.8,9


   Aim of the work
Top
 Abstract
 Introduction
 Aim of the work
Patients and methods
 Results
 Discussion
 Study limitations
 Conclusion
 References
 
To validate the accuracy of mitral annular motion (MAM) assessed by Doppler tissue imaging (DTI) and M-mode echocardiography (MME) as a surrogate for determination of LV function in comparison with BNP.


   Patients and methods
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
Results
 Discussion
 Study limitations
 Conclusion
 References
 
The current study included 133 patients with a variety of cardiac pathologies referred for echocardiography and 20 healthy age and sex matched volunteers as a control group.

For each patient the following was done:

(1) Detailed history talking.
(2) Thorough clinical examination.
(3) Standard 12 lead electrocardiogram (ECG).
(4) Convensional echocardiographic examination: Echocardiography was performed with the patients in the left lateral decubitus position. The equipment used was Acuson 128 XP 10 C system equipped with DTI technology. Measurements were performed according to the recommendations of the American Society of Echocardiography.10 Two-dimensional imaging examination was performed in the standard fashion in parasternal long- and short-axis views and apical 4- and 2-chamber views.11 Pulsed Doppler spectral recordings were obtained in the apical 4-chamber view from a 4mm sample volume placed at the tips of mitral valve.
Echocardiograms were subject to careful visual analysis to detect regional contractile abnormalities. LV systolic and diastolic volumes, and ejection fraction were derived from biplane apical (2- and 4-chamber) views using the modified Simpson's rule algorithm.12 The transmitral pulsed Doppler velocity recordings from three consecutive cardiac cycles were used to derive measurements as follows: peak velocities reached in early diastole (E) and after atrial contraction (A), and deceleration time (DT) was the interval from E-wave to the decline of velocity to baseline. In those cases in which velocity did not return to baseline, extrapolation of the deceleration signal was performed.
Displacement of the mitral annulus was measured in millimeters (mm) by MME from four different points (septal, lateral, inferior and anterior mitral annuli) by apical four-chamber and apical two-chamber approaches. Analysis was performed for the average of MAPSE measured at the four annular sites.
(5) DTI Examination: DTI of the mitral annulus was obtained from the apical (2- and 4-chamber) views after filters were set to exclude high-frequency signals (which is obtained by activating the DTI mode of the machine). A 5-mm sample volume was placed sequentially at the septal, lateral, inferior and anterior mitral annuli. The resulting velocities were recorded for 3 consecutive cardiac cycles at a sweep speed of 100mm/s. The following measurements were made from the recordings: peak systolic velocity (Sm), early (Em) and late (Am) diastolic velocities. Analysis was performed for the average of each velocity wave measured at the four annular sites.13 All Doppler echocardiographic and DTI recordings were obtained during normal respiration. The data were stored on a 1/2-inch VHS videotape for subsequent playback, measurement and analysis. All echocardiograms were interpreted by a cardiologist who was blinded to the BNP levels.
(6) Measurement of BNP levels: All samples were collected by venipuncture into EDTA tubes within 2hours of obtaining the echocardiogram. The blood samples were kept at room temperature and analyzed within 4hours of sampling using the Triage BNP assay (Biosite diagnostics). In some cases, the sample was centrifuged and the plasma was frozen for 1 to 2days at –70°C. Before analysis, each tube was inverted several times to ensure homogeneity. The BNP assay was a sandwich immunoassay that consisted of a disposable device to which 250µL of EDTA-anticoagulated whole blood or plasma was added. The Triage meter was used to measure the BNP concentration by detecting a fluorescent signal that reflected the amount of BNP in the sample.
Once 250µL of whole blood or plasma was added to the device, the cells were separated from the plasma by a filter, and the plasma containing BNP entered a reaction chamber that contained fluorescent-tagged BNP antibodies to form a reaction mixture. The reaction mixture was incubated for 2minutes and then migrated through the diagnostic lane by capillary action to a zone of immobilized antibody that would bind the desired BNP-fluorescent antibody complex. The unbound fluorescent antibodies were washed away by excess sample fluid. After 15minutes, the device was placed into the Triage meter, which measured the fluorescence intensity of the BNP assay zone. The Triage meter then correlated the fluorescence measurement to BNP concentration by use of an internal calibration curve. The assay was completed in 15minutes.14

Control group
Twenty healthy normal volunteers with no evidence of hypertension, diabetes, or any other known cause of heart disease were identified as the control group. This group included (17 males and 3 females with mean age 49.6±9.7years). In this group, EF of LV, Doppler recordings of the mitral inflow, MME and PWDTI data (from each of 4 mitral annulus sites inferior, anterior, septum and lateral) were obtained, also BNP levels were estimated in the same manner like the patients group. These data were used as reference values.

Statistical analysis
Data were collected and statistically analyzed using SPSS version (11.5). Descriptive statistics (e.g. number, percent, mean, standard deviation [SD]) and analytic statistics (e.g. Student's t test) were applied. ROC curve was applied to identify the appropriate cutoff point that have the best sensitivity and specificity. Sensitivity, specificity, positive, negative predictive values and accuracy were plotted against the range of cutoff values. A P value of <0.05 was considered statistically significant. Analysis of variance (ANOVA, F test) was used to assess the difference between more than two means. Least Significance Difference (LSD) was used to compare each individual mean.


   Results
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
 Results
Discussion
 Study limitations
 Conclusion
 References
 
The current study included 133 patients (109 males and 24 females with mean age 52.9±9.9years) with different cardiac pathologies referred for echocardiography and 20 healthy normal volunteers as a control group (17 males and 3 females with mean age 49.6±9.7years). The patients group included 66 patients with coronary artery disease, 44 patients with dilated cardiomyopathy, 13 patients with only diastolic dysfunction, and 10 patients with no significant echocardiographic abnormalities.

According to the LVEF, patients were divided into 2 groups, group (1) with LVEF >50% and Group (2) with LVEF <50%. Each group is compared to the other and to the control group regarding all the studied echocardiographic and biochemical variables (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1 Comparison between control group, group (1) and (2)

 
No significant difference was found between each of the 2 groups and control group as regard the age. By comparing group (1) and the control group, no significant difference was found except for Em (significantly lower in group 1), E/Em ratio and BNP levels (significantly higher in group 1). A significant difference was detected by comparing group (2) with each of group (1) and the control group regarding all the studied variables, where group (2) had significantly lower Sm, Em, MAPSE and LVEF but LVEDD, E/Em and BNP levels were significantly higher (P<0.001 for all) (Table 1).

BNP levels
ANOVA test (Table 2) and Least Significant Difference (LSD) test were used to compare BNP levels in different subgroups, where BNP levels were significantly higher in patients with combined systolic and diastolic dysfunction than those with only systolic dysfunction, the later group had significantly higher BNP levels than those with only diastolic dysfunction (1054.5±202.3pg/ml vs. 500±39.9pg/ml and 500±39.9pg/ml vs. 215.3±100.9pg/ml respectively, P<0.001 for all).


View this table:
[in this window]
[in a new window]

  		Table 2 Analysis of variance "ANOVA test"

 
The group of patients with LV dilation, had significantly higher BNP levels than those with normal LVEDD (643.9±312.7pg/ml vs. 238.1±89.4pg/ml, P<0.001). No significant difference was detected in BNP levels between the group of patients with (proven coronary artery disease without significant echocardiographic abnormality) and the group of patients with only diastolic dysfunction (267.2±14.8pg/ml vs. 215.3±100.8pg/ml, P=0.192) but BNP levels were significantly higher in each group than the group without significant clinical or echocardiographic abnormality (80.3±7.6pg/ml, P<0.001). Each of the previously mentioned subgroups had significantly higher BNP levels than control group (12.3±5.7pg/ml), P<0.001.

Criteria of the validity of PWDTI, MME and BNP for detection of LV dysfunction
MAPSE <12mm determined by MME has 90% sensitivity, 88% specificity, 90% positive predictive value, 88% negative predictive value and 89% accuracy for detection of LVEF <50%, while these values are 94%, 93%, 94%, 93% and 94% respectively for (Sm) <8cm/s determined by PWDTI. BNP level >75pg/ml has 98% sensitivity, 90% specificity, 98% positive predictive value, 90% negative predictive value and 97% accuracy for detection of LV dysfunction (either systolic, diastolic or both; Table 3 and Figs. 1–3GoGo).


Figure 1
View larger version (32K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Criteria of the validity of PWDTI, MME for detection of LVEF <50% and for BNP level >75pg/ml. for detection of LV dysfunction (systolic, diastolic or both).

 


Figure 2
View larger version (79K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Example for a patient group (1), LVEF=65%, showing different values for MAPSE, Sm and Em measured at the 4 mitral annular sites.

 


Figure 3
View larger version (77K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Example for a patient group (2), LVEF=30%, showing different values for MAPSE, Sm and Em measured at the 4 mitral annular sites.

 


View this table:
[in this window]
[in a new window]

  		Table 3 Criteria of the validity of PWDTI, MME for detection of LVEF <50% and for BNP level >75pg for detection of LV dysfunction (systolic, diastolic or both)

 
Correlation of echocardiographic variables with BNP levels
Significant correlations (P<0.001 for all) were found between BNP levels and the examined echocardiographic variables. Positive correlations (Figs. 4 and 5Go) were observed between BNP and each of early transmitral (E) to Em ratio (r=0.61) and LV end diastolic dimension (r=0.63). Strong negative correlation (Figs. 6–8GoGo) was found between BNP and each of Em (r=–0.82), Sm (r=–0.7) and LVEF (r=–0.64) while a less negative but still significant correlation (Fig. 9) was observed between BNP and MAPSE (r=–0.54).


Figure 4
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Correlation between BNP and MAPSE (r=–0.54, P<0.001).

 


Figure 5
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 5 Correlation between BNP and Sm (r=–0.7, P<0.001).

 


Figure 6
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 6 Correlation between BNP and Em (r=–0.815, P<0.001).

 


Figure 7
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 7 Correlation between BNP and E/Em (r=0.605, P<0.001).

 


Figure 8
View larger version (12K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 8 Correlation between BNP and LVEDD (r=0.625, P<0.001).

 


Figure 9
View larger version (11K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 9 Correlation between BNP and LVEF (r=–0.635, P<0.001).

 
There was a weak relationship between BNP levels and E/Em ratios in patients with normal LV function (r=0.19). In contrast, the correlation was better in patients with diastolic dysfunction (r=0.65). This correlation was even greater in patients with combined systolic and diastolic dysfunction (r=0.72).


   Discussion
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
 Results
 Discussion
Study limitations
 Conclusion
 References
 
The mitral annular ring motion has a complex three-dimensional pattern. It has three main components: motion along the ventricular long axis (base to apex), rotation, and sphincter-like motion. A distinctive motion of the mitral annular ring in the base-to-apex direction was first described in details by Zaky et al.15 by B-form echocardiography. This apical displacement represents shortening of the left ventricle along its long axis and can be measured by M-mode or two-dimensional echocardiography. Mitral annular displacement has been proposed as a method of measuring left ventricular systolic and diastolic function and as an index of left atrial function.16–19 Normally, the mitral annulus moves down toward the ventricle during systole and up toward the atrium in early diastole and atrial systole. Simonson and Schiller16 and Pai et al.18 found a strong correlation between the systolic annular displacement measured by two-dimensional echo and left ventricular ejection fraction. It has been hypothesized that the early diastolic annular motion is related to left ventricular recoil.20 Abnormalities of the mitral annular motion have been described in a variety of conditions, Alam et al.21 described decreased mitral annulus excursion in patients with coronary artery disease compared with healthy patients. Patients with acute myocardial infarction also showed reduced displacement more marked at the region of the annulus related to the infarcted wall.22 Recently, the effects of exercise on mitral annular motion in healthy subjects and in patients with angiographically verified coronary artery disease have been reported.23 Assessment of diastolic function by using mitral annulus displacement has also been reported.17,19

The LV wall is composed of both circular and longitudinal myocardial fibers. The later fibers dominate in subepicardial and subendocardial layers and in the papillary muscles. Apart from anatomic, there are important functional distinctions with the longitudinal fibers contracting earlier than the circular fibers.20,24

Cardiac disorders can impair both longitudinal and radial contractile function. However, it has been suggested that in pathologic conditions (e.g., myocardial ischemia or hypertrophy), long-axis myocardial function is impaired first.5,25 Therefore, the analysis of longitudinal myocardial function could help in early diagnosis of cardiac dysfunction.

Assessment of mitral annular motion
M-mode echocardiography (MME)
In the current study, MAM was assessed by MME where a value of 12mm was selected (by ROC curve) as a cutoff point for MAPSE which is the point with best validity criteria (90% sensitivity, 88% specificity and 89% accuracy) for detection of LVEF <50%. Qin et al.26 have reported (96% sensitivity, 85% specificity and 91% accuracy) for MAM <12mm as a cutoff point of MAPSE for detection of LVEF <50% but assessment of MAM was done by three-dimensional echocardiography and LVEF was estimated by magnetic resonance imaging (MRI).

MAPSE was significantly higher in patients with LVEF >50% and control group than those with LVEF <50% (P<0.001), while no significant difference was found between control group and patients with LVEF >50% (P >0.05) this goes parallel to data reported by Stoylen and Skjaerpe27 who demonstrated significant reduction of annular motion and velocity in patients with myocardial infarction who had reduced LVEF compared with the control group.

The present study has demonstrated a significant correlation between MAPSE and LVEF (r=0.81, P<0.001) accordingly MAPSE can be used as good indicator of LV systolic function, this goes in agreement with several echocardiographic studies26–28 that have shown good agreement between LVEF and MAPSEx5, where MAPSE is the total mitral annular plane systolic excursion, measured in mm, and LVEF is expressed as a percentage. This means that if MAPSE is used for estimation of left ventricular function, the conversion factor 5 is used, if the function is expressed as EF. Qin et al.26 have reported that, MAPSE is correlated moderately well with LVEF measured by MRI (r=0.84, P<0.0001). Cevik et al.29 postulated that, LVEF calculated by cineangiography, was moderately correlated with the Teichholz method for measurement of LVEF (r=0.66) while it was highly correlated with measurements of MAPSE (r=0.87). This correlation can be expressed by the regression equation, LVEF (by cineangiography)=5.7xMAPSE (in mm) – 6.5.

Pulsed-wave Doppler tissue imaging (PWDTI)
Unlike M-mode echocardiography, PWDTI allows not only calculation of amplitude, but also the velocity (systolic, early and late diastolic) and acceleration of mitral annular motion.30 In the current study, MAM was assessed by PWDTI, where peak systolic annular velocity (Sm) was measured to evaluate systolic function and, early (Em) diastolic annular velocity evaluate early diastolic function, where a value of 8cm/s was selected (by ROC curve) as a cutoff point for Sm which is the point with best validity criteria (94% sensitivity, 93% specificity and 94% accuracy) for detection of LVEF <50%. Vinereanu et al.31 have reported (80% sensitivity, 89% specificity) for the same cutoff point of Sm measured at the medial mitral annulus and (80% sensitivity, 92% specificity) for Sm measured at the lateral mitral annulus.

Sm was significantly higher in both patients with LVEF >50% and control group than those with LVEF <50% (P<0.001), while no significant difference was found between control group and patients with LVEF >50% (P >0.05) this goes parallel to data reported by Alam et al.32 who demonstrated significant reduction of the mitral and tricuspid annular velocities in patients with CHF compared with healthy participants.

The present study has demonstrated a significant correlation between Sm and LVEF in the whole study population (r=0.94, P<0.001). Sm is moderately correlated with LVEF in group (2) with LVEF <50% (r=71, P<0.001), while in group (1) with LVEF >50%, a stronger correlation was found (r=0.82, P<0.001) accordingly Sm can be used as sensitive indicator of LV systolic function, this observation goes in agreement with those of Vinereanu et al.31 who found that, Peak systolic velocities of medial and lateral mitral annular motion correlated with LVEF (r=0.55 and 0.54, respectively; P<0.001), Correlations were higher in normal ventricles (r=0.62–0.69 respectively; P<0.001) than in patients with previous myocardial infarction (r=0.39–0.64 respectively; P<0.001). The difference in this case in the strength of correlation compared to our study, may be attributed to the fact that, assessment of MAM in case of Vinereanu et al.31 was performed at the medial and lateral mitral annuli only, while in the present study evaluation was performed at the four annular sites and averaged so it gives a better expression of the global LV function which accounts for the stronger correlation in the current study.

Alam et al.32 postulated that, the correlation between LVEF and the systolic mitral annular velocity is relatively good irrespective of the presence or absence of significant mitral regurgitation (r=0.61, P<0.001).

The transmitral velocity E is preload dependent and early (Em) diastolic annular velocity is related to LV relaxation, the ratio E/Em can be used to estimate LV filling pressures. An E/Em ratio >15 is highly specific for elevated LV end diastolic pressure, whereas E/Em ≤8 is very specific for normal to low filling pressures. The combination of early (Em) diastolic annular and mitral inflow velocities has been shown to provide better estimates of LV filling pressures than other methods.33

In the current study, Em was significantly lower in group (2) than group (1), and lower in each group than control group (P<0.001 for all), while E/Em ratio was significantly higher in group (2) than group (1), and higher in each group than control group (P<0.001 for all) this reflects clearly the ability of PWDTI for early detection of diastolic dysfunction and evaluation of LV filling pressure even in patients with preserved LVEF (normal systolic function) in contrast to conventional transmitral parameters alone which correlate poorly with LV filling pressure in patients with normal systolic function.33

BNP levels
In the current study, LV function was assessed by estimation of BNP level where a value of 75pg/ml was selected (by ROC curve) as a cutoff point for detection of LV dysfunction (diastolic, systolic or both) which is the point with best validity criteria (98% sensitivity, 90% specificity and 97% accuracy). Lubarsky et al.34 have reported (90% sensitivity, 98% specificity and 93% accuracy) for the same cutoff point of BNP measured by rapid bedside immunoassay for detection of LV dysfunction.

McCullough et al.35 postulated that, a cutoff of 100pg/mL for BNP had a sensitivity of 90% and specificity of 73% in setting of evaluation of acute dyspnea for heart failure diagnosis in the emergency department.

In the current study, BNP levels were significantly higher in patients with combined systolic and diastolic dysfunction than those with only systolic dysfunction, the later group had significantly higher BNP levels than those with only diastolic dysfunction. Significantly higher BNP levels were detected in patients with LV dilation, than those with normal LVEDD, and in patients with reported echocardiographic abnormalities than the group without echocardiographic abnormality and all had significantly higher BNP levels than control group (P<0.001 for all). A closely similar findings were reported by Lubarsky et al.34

Accordingly, an elevated BNP, has been associated with both the presence and severity of ventricular dysfunction. This is not the only finding of significance that can be derived from BNP measurement, but of note is the high negative predictive value of BNP in the current study and in concordance with many other studies.36–41 This makes BNP assessment very useful for excluding cardiac dysfunction in the setting of emergency evaluation of symptoms that mimic those of cardiac origin.

Correlation of echocardiographic variables with BNP levels
In the present study, significant correlations (P<0.001 for all) were found between BNP levels and the examined echocardiographic variables. Strong negative correlation was found between BNP and each of Em (r=–0.82), Sm (r=–0.7) and LVEF(r=–0.64) while a less negative but still significant correlation was observed between BNP and MAPSE (r=–0.54).

Vinereanu et al.42 postulated that, global systolic function (LVEF) correlated with BNP (r=–0.54), while LV longitudinal systolic function had a stronger correlation (r=–0.78, P<0.001). They detected sensitivity and specificity of a longitudinal systolic velocity of ≤5.5cm/s (mean velocity of 4 basal segments, not the annular velocity) to diagnose heart failure (defined as an elevated BNP) were 94% and 85%, respectively; the negative predictive value was 97%.

On the other hand, Tretjak et al.43 detected significant correlations between BNP level and Em velocity (r=–0.79), Sm velocity (r=–0.43), LVEF (r=–0.44). In multiple regression model, the Em velocity was the most important predictor of BNP level.

Positive correlations were observed in the present study, between BNP and each of E/Em (r=0.61) and LV end diastolic dimension (r=0.63). Tretjak et al.43 reported, similar significant but weaker correlations (r=0.38, r=0.29 respectively).

Of note is the difference in this case in the strength of correlation (regarding Sm, LVEF, E/Em and LVEDD) may be attributed to the fact that, assessment of MAM in case of Tretjak et al.43 was performed at the medial and lateral mitral annuli only while in the present study evaluation was performed at the four annular sites and averaged so it gives a better expression of the global LV function which accounts for the stronger correlation in the current study, furthermore, the studied population in case of Tretjak et al.43 are all patients with heart failure.

In the present study, a weak relationship between BNP levels and E/Em ratio in patients with normal LV function (r=0.19). In contrast, the correlation was better in patients with diastolic dysfunction (r=0.65). This correlation was even greater in patients with combined systolic and diastolic dysfunction (r=0.72). These data are in close agreement with findings reported by Mak et al.33 who found a greater correlation in patients with combined systolic and diastolic dysfunction (r=0.66) than those with diastolic dysfunction (r=0.60). Accordingly, early diastolic mitral annular velocity measured by DTI correlates strongly with plasma BNP levels, and provides alone or in combination with the transmitral velocity E (E/Em), a simple, accurate and reproducible echocardiographic index of diastolic heart failure and evaluation of LV filling pressures in patients with preserved or reduced LVEF.


   Study limitations
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
 Results
 Discussion
 Study limitations
Conclusion
 References
 
The patient sample represents generally older, predominantly males. While we sought to examine an unselected group of patients who would be representative of a broader patient population, all patients were referred for clinically indicated echocardiography, and this represented a group of patients with a high prevalence of cardiac disease. DTI, pulsed Doppler, and M-mode tracings cannot be obtained simultaneously, but meticulous care was taken to measure cycles with identical R-R intervals. Left ventricular hypertrophy (LVH) is another limitation which may have an impact on the value of the measured annular velocities and excursions in comparison with the patients without LVH.


   Conclusion
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
 Results
 Discussion
 Study limitations
 Conclusion
References
 
M-mode echocardiography and PWDTI used for assessment of mitral annular motion are useful non-invasive methods for evaluation of LV function but parameters measured by PWDTI correlate more strongly with plasma BNP levels than those measured by MME and provide a simple, sensitive, accurate and reproducible tool for early diagnosis of LV systolic or diastolic dysfunction.


   References
Top
 Abstract
 Introduction
 Aim of the work
 Patients and methods
 Results
 Discussion
 Study limitations
 Conclusion
 References
 

  1. Timek T.A., Miller D.C. Experimental and clinical assessment of mitral annular area and dynamics: what are we actually measuring? Ann Thorac Surg (2001) 72(3):966–974.[Abstract/Free Full Text]
  2. Carlhall C., et al. Contribution of mitral annular excursion and shape dynamics to total left ventricular volume change. Am J Physiol Heart Circ Physiol (2004) 287:H1836–H1841.[Abstract/Free Full Text]
  3. Nikitin N.P., et al. Longitudinal ventricular function: normal values of atrioventricular annular and myocardial velocities measured with quantitative two-dimensional color Doppler tissue imaging. J Am Soc Echocardiogr (2003) 16:906–921.[CrossRef][Web of Science][Medline]
  4. Vinereanu D., Florescu N., Sculthorpe N., et al. Differentiation between pathologic and physiologic left ventricular hypertrophy by tissue Doppler assessment of long-axis function in patients with hypertrophic cardiomyopathy or systemic hypertension and in athletes. Am J Cardiol (2001) 88:53–58.[CrossRef][Web of Science][Medline]
  5. Bolognesi R., Tsialtas D., Barilli A.L., et al. Detection of early abnormalities of left ventricular function by hemodynamic, echo-tissue Doppler imaging, and mitral Doppler flow techniques in patients with coronary artery disease and normal ejection fraction. J Am Soc Echocardiogr (2001) 14:764–772.[CrossRef][Web of Science][Medline]
  6. Yip G., Wang M., Zhang Y., et al. Left ventricular long axis function in diastolic heart failure is reduced in both diastole and systole: time for a redefinition? Heart (2002) 87:121–125.[Abstract/Free Full Text]
  7. Vinereanu D., Khokhar A., Fraser A.G. Reproducibility of pulsed wave tissue Doppler echocardiography. J Am Soc Echocardiogr (1999) 12:492–499.[CrossRef][Web of Science][Medline]
  8. Yu C.M., Sanderson J.E., Shum I.O.L., et al. Diastolic dysfunction and natriuretic peptides in systolic heart failure. Eur Heart J (1996) 17:1694–1702.[Abstract/Free Full Text]
  9. Maisel A.S., Krishnaswamy P., Nowak R.M., et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med (2002) 347:161–167.[Abstract/Free Full Text]
  10. Schiller N.B., Shah P.M., Crawford M., et al. Recommendations for quantitation of the left ventricle by 2-dimensional echocardiography. J Am Soc Echocardiogr (1989) 2:358–367.[Medline]
  11. Feigenbaum H. Echocardiography. (1999) 6th ed. Philadelphia: Lea and Febiger.
  12. Schiller N.B., Acquatella H., Ports T.A., et al. Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation (1979) 60:547.[Abstract/Free Full Text]
  13. Waggoner A.D., Bierig S.M. Tissue Doppler imaging: a useful echocardiographic method for the cardiac sonographer to assess systolic and diastolic ventricular function. J Am Soc Echocardiogr (2001) 14:1143–1152.[CrossRef][Web of Science][Medline]
  14. Dao Q., Krishnaswamy P., Kazanegra R., et al. Utility of B-type natriuretic peptide (BNP) in the diagnosis of CHF in an urgent care setting. J Am Coll Cardiol (2001) 37:379–385.[Abstract/Free Full Text]
  15. Zaky A., Grabhorn L., Feigenbaum H. Movement of the mitral ring: a study in ultrasound cardiography. Cardiovasc Res (1967) 1:121–131.[Abstract/Free Full Text]
  16. Simonson J., Schiller N.B. Descent of the base of the left ventricle: an echocardiographic index of left ventricular function. J Am Soc Echo (1989) 2:25–35.[Medline]
  17. Jones C.J., Song G.J., Gibson D.G. An echocardiographic assessment of atrial mechanical behavior. Br Heart J (1991) 65:31–36.[Abstract/Free Full Text]
  18. Pai R.G., Bodenheimer M.M., Pai S.M., et al. Usefulness of systolic excursion of the mitral anulus as an index of left ventricular systolic function. Am J Cardiol (1991) 67:222–224.[CrossRef][Web of Science][Medline]
  19. Alam M., Hoglund C. Assessment by echocardiogram of left ventricular diastolic function in healthy subjects using the atrioventricular plane displacement. Am J Cardiol (1992) 69:565–568.[Web of Science][Medline]
  20. Jones C.J., Raposo L., Gibson D.G. Functional importance of the long axis dynamics of the human left ventricle. Br Heart J (1990) 63:215–220.[Abstract/Free Full Text]
  21. Alam M., Hoglund C., Thorstrand C., et al. Haemodynamic significance of the atrioventricular plane displacement in patients with coronary artery disease. Eur Heart J (1992) 13:194–200.[Abstract/Free Full Text]
  22. Hoglund C., Alam M., Thorstrand C. Effects of acute myocardial infarction on the displacement of the atrioventricular plane: an echocardiographic study. J Int Med (1989) 226:251–256.[Web of Science][Medline]
  23. Alam M., Hoglund C., Thorstrand C., et al. Effects of exercise on the displacement of the atrioventricular plane in patients with coronary artery disease. A new echocardiographic method of detecting reversible myocardial ischaemia. Eur Heart J (1991) 12:760–765.[Web of Science][Medline]
  24. Greenbaum R.A., Ho S.Y., Gibson D.G., et al. Left ventricular fibre architecture in man. Br Heart J (1981) 45:248–263.[Abstract/Free Full Text]
  25. Henein M.Y., Anagnostopoulos C., Das S.K., et al. Left ventricular long axis disturbances as predictors for thallium perfusion defects in patients with known peripheral vascular disease. Heart (1998) 79:295–300.[Abstract/Free Full Text]
  26. Qin J.X., Shiota T., Tsujino H., et al. Mitral annular motion as a surrogate for left ventricular ejection fraction: real – time three-dimensional echocardiography and magnetic resonance imaging studies. Eur J Echocardiogr (2004) 5:407–415.
  27. Stoylen A., Skjaerpe T. Systolic long axis function of the left ventricle. Global and regional information. Scand Cardiovasc J (2003) 37(5):253–258.[CrossRef][Web of Science][Medline]
  28. Emilsson K., Wandt B. The relation between mitral annulus motion and ejection fraction changes with age and heart size. Clin Physiol (2000) 20(1):38–43.[CrossRef][Web of Science][Medline]
  29. Cevik Y., et al. A new echocardiographic formula to calculate ejection fraction by using systolic excursion of mitral annulus. Angiology (1995) 46:157–163.[Web of Science][Medline]
  30. Nikitin N.P., Witte K.A., Thackray S. Longitudinal ventricular function: normal values of atrioventricular annular and myocardial velocities measured with quantitative two-dimensional color Doppler tissue imaging. J Am Soc Echocardiogr (2003) 16:906–921.[CrossRef][Web of Science][Medline]
  31. Vinereanu D., Khokhar A., Tweddel A.C., et al. Estimation of global left ventricular function from the velocity of longitudinal shortening. Echocardiography (2002) 19(3):177–185.[CrossRef][Web of Science][Medline]
  32. Alam M., Wardell J., Andersson E., et al. Assessment of left ventricular function using mitral annular velocities in patients with congestive heart failure with or without the presence of significant mitral regurgitation. J Am Soc Echocardiogr (2003) 16(3):240–245.[CrossRef][Web of Science][Medline]
  33. Mak G.S., Demaria A., Clopton P., et al. Utility of B-natriuretic peptide in the evaluation of left ventricular diastolic function: comparison with tissue Doppler imaging recordings. Am Heart J (2004) 148(5):895–902.[CrossRef][Web of Science][Medline]
  34. Lubarsky L., Mandell K., Coplan N.L. B-type natriuretic peptide: practical diagnostic use for evaluating ventricular dysfunction. CHF (2004) 10(3):140–143.[Medline]
  35. McCullough P.A., Nowak R.M., McCord J., et al. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure. Circulation (2002) 106:416–422.[Abstract/Free Full Text]
  36. Talwar S., Downie P.F., Ng L.L., et al. Toward a blood test for heart failure: the potential use of circulating natriuretic peptide. Br J Clin Pharmacol (2000) 50:15–20.[CrossRef][Web of Science][Medline]
  37. Yamamoto K., Burnett J.C. Jr., Jougasaki M., et al. Superiority of brain natriuretic peptide as a hormonal marker of ventricular systolic and diastolic dysfunction and ventricular hypertrophy. Hypertension (1996) 28:988–994.[Abstract/Free Full Text]
  38. Maisel A.S., Krishnaswamy P., Nowak R.M. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med (2002) 347:161–167.[Abstract/Free Full Text]
  39. Dao Q., Krishnaswamy P., Kazanegra R., et al. B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol (2001) 37:379–385.[Abstract/Free Full Text]
  40. Morrison L.K., Harrison A., Krishnaswamy P., et al. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol (2002) 39:202–209.[Abstract/Free Full Text]
  41. Maisel A., Koon J., Krishnaswamy P., et al. Utility of BNP as a rapid, point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction. Am Heart J (2001) 141:367–374.[CrossRef][Web of Science][Medline]
  42. Vinereanu D, Lim PO, Frenneaux MP, et al. Reduced myocardial velocities of left ventricular long-axis contraction identify both systolic and diastolic heart failure—a comparison with brain natriuretic peptide. Corrected Proof, 9 December 2004 European Journal of Heart Failure.
  43. Tretjak M, Verovnik F, Benko D, et al. Tissue Doppler velocities of mitral annulus and NT-proBNP in patients with heart failure. Corrected Proof, 8 December 2004 European Journal of Heart Failure.

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur J EchocardiogrHome page
P. Ballo, A. Bocelli, A. Motto, and S. Mondillo
Concordance between M-mode, pulsed Tissue Doppler, and colour Tissue Doppler in the assessment of mitral annulus systolic excursion in normal subjects
Eur J Echocardiogr, November 1, 2008; 9(6): 748 - 753.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Elnoamany, M. F.
Right arrow Articles by Abdelhameed, A. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Elnoamany, M. F.
Right arrow Articles by Abdelhameed, A. K.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?