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European Journal of Echocardiography 2007 8(1):37-41; doi:10.1016/j.euje.2005.12.012
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Copyright © 2006, The European Society of Cardiology

Detection of abnormal left ventricular function by Doppler tissue imaging in patients with a first myocardial infarction and showing normal function assessed by conventional echocardiography

Mahbubul Alam*, Nils Witt, Rolf Nordlander and Bassem A. Samad

Department of Cardiology, Karolinska Institute at South Hospital (Södersjukhuset), 118 83 Stockholm, Sweden

Received 12 July 2005; received in revised form 14 December 2005; accepted after revision 23 December 2005.

* Corresponding author. Tel.: +46 8 6161000; fax:+46 8 6163040. mahbubul.alam{at}sodersjukhuset.se


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgment
 References
 
Aims The aim of the study was to characterize left ventricular (LV) function by Doppler tissue imaging (DTI) after a first myocardial infarction (MI) where the conventional echo-Doppler parameters showed no abnormalities.

Methods Out of 202 patients who were referred for an echocardiogram, 19 patients were previously healthy and had a normal ejection fraction and no wall motion abnormalities at echocardiogram. These 19 patients were compared with 16 age-matched healthy subjects (HS). The longitudinal LV function was assessed using the mitral annular velocities (mean value from four different sites of the LV) determined by DTI.

Results The patients with MI had significantly reduced peak systolic and peak early diastolic mitral annular velocities compared to HS (8.6 v. 9.7cm/s, P<0.001 for systolic velocity, and 10.9 v. 12.3cm/s, P<0.01 for diastolic velocity, respectively). The patients had normal diastolic LV function assessed by the conventional Doppler echocardiogram (e.g. transmitral flow, IVRT and pulmonary venous flow patterns). To assess the LV filling pressure, the ratio of the transmitral early wave velocity assessed by conventional echo-Doppler and peak early diastolic mitral annular velocity determined by DTI (E/Edti) was used. The E/Edti was significantly higher in patients than in HS (7.0 v. 5.7, P<0.05).

Conclusion Previously healthy subjects who are suffering from a first MI and showing normal systolic and diastolic LV function, determined by conventional echo-Doppler methods, show decreased mitral annular systolic and diastolic velocities determined by DTI compared to healthy subjects. This is probably evidence of mild subendocardial damage due to MI that remains undetected by conventional echo-Doppler methods.

Keywords: LV; left ventricle; MI; myocardial infarction; HS; healthy subjects; DTI; Doppler tissue imaging


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Acknowledgment
 References
 
Echocardiographic examination after a myocardial infarction (MI) is a routine procedure. Assessment of left ventricular (LV) function after an MI has clinical significance. Reduced systolic and diastolic functions are common findings after an MI. However, theoretically, a minor MI might show normal systolic and diastolic LV function in otherwise healthy patients. It is common practice to assess LV ejection fraction and regional wall motion abnormalities to describe the systolic LV function. Parameters that are used to assess LV diastolic function are transmitral flow velocity profiles, isovolumic relaxation time and pulmonary venous flow patterns. In recent years, myocardial velocities determined by Doppler tissue imaging (DTI) have been used to analyze LV function. Using the mitral annular velocities, LV systolic and diastolic functions have been shown to be decreased in various clinical conditions, e.g. acute MI, congestive heart failure etc.1–4 The characteristics of myocardial velocities in patients with acute MI and normal findings at conventional echo-Doppler examination are not known. The purpose of the present study using DTI is to characterize the mitral annular velocities in otherwise healthy patients suffering from a first acute MI and showing normal systolic and diastolic LV function as assessed by conventional echo-Doppler methods.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Acknowledgment
 References
 
Subjects
We started with 202 patients with a first acute MI who were referred for echocardiography. Nineteen of them (15 male and 4 female) had normal systolic and diastolic LV function according to the conventional echo-Doppler parameters. All these 19 patients had been healthy previously and without any history of disease, e.g., hypertension, diabetes mellitus or cardio-pulmonary disease. Four of them were smokers. The MI was diagnosed on the basis of characteristic chest pain and diagnostic serial changes in cardiac enzymes (CKMB more than 10µg/l and at least three times more than total CK or Troponin-T >0.2µg/l) with or without the presence of EKG changes. None of these 19 patients developed Q-waves and all of them were in sinus rhythm. In the presence of ST-elevation on the EKG the patients were treated either by percutaneous coronary intervention or thrombolysis. Otherwise they were treated by low molecular weight heparin. All the patients received beta blockers if there was no contraindication. Patients with suspected myocarditis were excluded. Sixteen age-matched healthy subjects (12 males and 4 females) with normal findings on the resting EKG and at echocardiography and without a history of cardiac disease or systemic hypertension served as controls. Three of the controls were smokers.

Conventional echocardiography
A Hewlett-Packard Sonos 5500 (Andover, MA) phased array system equipped with DTI technology was used. All the subjects were examined in the left lateral decubitus position 2–4days after MI. Recordings and calculations of different cardiac chambers and ejection fractions were made according to the recommendations of the American Society of Echocardiography.5 A visual wall motion analysis was assessed by two independent experts without prior knowledge of the patients' clinical data. The different LV diastolic parameters, e.g. transmitral early wave velocity, mitral early wave deceleration time, isovolumic relaxation time and pulmonary venous flow, were recorded in a standard way as previously described.6–8

Mitral annular velocity by DTI
By activating the DTI function in the echocardiography machine the mitral annular velocities were recorded using the pulsed-wave DTI. A variable frequency phased array transducer (2.0–4.0MHz) was used. The filter settings were kept low (50Hz) and gains were adjusted at the optimal level for good quality velocity. A 1.7mm sample volume was used. From the apical 4- and 2-chamber views, the longitudinal mitral annular velocities were recorded from septal, lateral, inferior and anterior LV sites as described previously.9 A mean value for the above four sites was used to assess global systolic and diastolic function. Three major velocities were taken into account: the positive peak systolic velocity when the mitral ring moved toward the cardiac apex due to longitudinal contraction of the LV and two negative diastolic velocities when the mitral annulus moved toward the base away from the apex, one during the early phase of diastole and the other in the late phase of diastole. A mean of three consecutive cycles was used to calculate all echo-Doppler parameters.

Statistics
The numerical values are expressed as means and one standard deviation. Comparisons between healthy subjects and patients were made using Student's unpaired t-test. A P-value <0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Acknowledgment
 References
 
All 19 patients had normal ejection fraction. None of them showed any sign of hypertrophy or abnormal wall motion of the LV. The CKMB level was 80±79µg/l. The basic clinical and echocardiographic parameters of the patients, as compared to healthy subjects are shown in Table 1. All the conventional diastolic parameters of the LV were normal in the patients and were similar to those of the healthy subjects (Table 2). The mean mitral annular velocities (an average for septal, lateral, inferior, and anterior LV sites) are shown in Table 3. Compared to healthy subjects, the patients had significantly decreased peak systolic and peak diastolic velocities. The distribution of systolic myocardial velocities in patients and controls are shown in Fig. 1. To assess the LV filling pressure, the ratio of the transmitral early wave velocity determined by conventional Doppler and the peak early diastolic mitral annular velocity determined by DTI was calculated (E/Edti). The E/Edti was higher in patients than in healthy subjects.


Figure 1
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  		Figure 1 Diagram showing the distribution of the peak systolic velocity in healthy subjects and in patients with myocardial infarction and normal left ventricular function according to conventional echocardiography.

 


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  		Table 1 Basic clinical and echocardiographic parameters for healthy subjects (HS) and patients with acute myocardial infarction (MI)

 


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  		Table 2 Diastolic left ventricular function assessed by conventional Doppler parameters in healthy subjects (HS) and patients with acute myocardial infarction (MI)

 


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  		Table 3 Mitral annular velocity (MAV) determined by Doppler tissue imaging in patients with acute myocardial infarction (MI) and in healthy subjects (HS)

 
In addition, the results of LV function assessed by DTI in other MI patients with abnormal wall motion or reduced ejection fraction (available in 167 patients) have been shown in Table 3.


   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Acknowledgment
 References
 
Systolic LV velocity by DTI
Systolic LV function after an MI is usually assessed by determining the LV ejection fraction and by wall motion analysis. Some previous studies reported the use of 2-D guided M-mode recording of the mitral annular motion to analyze LV function. Following an acute MI, the patients usually showed a reduced ejection fraction and abnormal wall motion as well as decreased mitral annular motion compared to healthy subjects.10 In recent years, myocardial velocities determined by DTI have been used to characterize LV systolic function in various clinical conditions. Recording of mitral annular velocity along the long axis reflects LV function predominantly due to longitudinally oriented fiber contraction. In the presence of a decreased ejection fraction and abnormal wall motion in most of the patients in the present study, the systolic myocardial velocity has been found to be reduced when recordings were made along the longitudinal axis of the LV. However, these findings are not new.3,11,12

In the absence of abnormal wall motion the characteristics of myocardial velocities are not known. Thereby emphasis was given in the present study to analyze patients with normal findings at the conventional echocardiography. In the presence of subendocardial MI, the longitudinally oriented cardiac fibers are the ones mainly affected.13 In the present study, the subgroup of patients with a completely normal ejection fraction and no sign of wall motion abnormality were properly comparable with healthy subjects regarding age, sex, smoking and absence of previous illness The finding of a decreased systolic myocardial velocity in these patients is interesting. It can be hypothesized that the patients suffered such a minor MI involving only a limited subendocardial area that it could not be detected by wall motion analysis. Mitral annular velocity recordings are probably more sensitive than conventional methods and thus could identify decreased systolic velocity in patients with MI in the present study.

Diastolic LV velocity by DTI
The determination of diastolic function has clinical significance after MI. Using conventional methods, the transmitral flow velocity, isovolumic relaxation time, and pulmonary venous flow patterns are frequently used to identify patients with diastolic dysfunction. In the present study, the diastolic function assessed by all the conventional methods was found to be normal. In addition, no difference was noted compared to the diastolic function of the healthy subjects. However, using DTI, the diastolic velocities were found to be significantly decreased in patients compared to healthy subjects. Several previous studies have observed the clinical significance of peak early diastolic mitral annular velocities in different clinical conditions.11,14 Similarly to decreased systolic mitral annular velocity, the decreased early diastolic velocity in patients with MI might be a sign of minor subendocardial damage after the MI that could not be detected using conventional parameters. Previous studies have reported that the ratio between the transmitral early wave velocity and the peak early diastolic mitral annular velocity, E/Edti, reflects LV filling pressure.15 A high value, especially ≥10, is a sign of increased LV filling pressure. In the present study, the E/Edti was higher in patients than in healthy subjects although the values remained <10.

In conclusion, patients with a first MI and having normal systolic and diastolic LV function, determined by conventional echo-Doppler methods, show decreased mitral annular systolic and diastolic velocities as determined by DTI, compared to healthy subjects. This is probably an expression of mild subendocardial damage due to MI which remains undetected by conventional echo-Doppler methods.

Limitations
The number of patients is small, which is the main limitation of the study. Although the mitral annular velocities are decreased compared to age-match healthy subjects, the clinical significance of this is not known. However, the findings in the present study are interesting. No inter- and intraobserver variations were tested in the study. The variations were not significant, however, in a previous study.9


   Acknowledgment
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgment
References
 
This study was supported by a grant from the Swedish Heart Lung Foundation.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgment
 References
 

  1. Galiuto L., Ignone G., DeMaria A.N. Contraction and relaxation velocities of the normal left ventricle using pulsed-wave tissue Doppler echocardiography. Am J Cardiol (1998) 81:609–614.[CrossRef][Web of Science][Medline]
  2. Derumeaux G., Ovize M., Loufoua L., Andre-Fouet X., Minaire Y., Cribier A., et al. Doppler tissue imaging quantitates regional wall motion during myocardial ischemia and reperfusion. Circulation (1998) 97:1970–1977.[Abstract/Free Full Text]
  3. Gulati V.K., Katz W.E., Follansbee W.P., Gorcsan J. 3rd. Mitral annular descent velocity by tissue Doppler echocardiography as an index of global left ventricular function. Am J Cardiol (1996) 77:979–984.[CrossRef][Web of Science][Medline]
  4. Alam M., Wardell J., Andersson E., Nordlander R., Samad B.A. 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) 16:240–245.[CrossRef][Web of Science][Medline]
  5. Schiller N.B., Shah P.M., Crawford M., DeMaria A., Devereux R., Feigenbaum H., et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr (1989) 2:358–367.[Medline]
  6. Appleton C.P., Jensen J.L., Hatle L.K., Oh J.K. Doppler evaluation of left and right ventricular diastolic function: A technical guide for obtaining optimal flow velocity recordings. J Am Soc Echocardiogr (1997) 10:271–291.[CrossRef][Web of Science][Medline]
  7. Rossvol O., Hatle L.K. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol (1993) 21:1687–1696.[Abstract]
  8. Appleton C.P., Galloway J.M., Gonzalez M.S., Gaballa M., Basnight M.A. Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult cardiac patients: additional value of analysing left atrial size, left atrial ejection fraction and the difference in the duration of pulmonary venous and mitral flow velocities at atrial contraction. J Am Coll Cardiol (1993) 22:1972–1982.[Abstract]
  9. Alam M., Wardell J., Andersson E., Samad B., Nordlander R. Characteristics of mitral and tricuspid annular velocities determined by pulsed wave Doppler tissue imaging in healthy subjects. J Am Soc Echocardiogr (1999) 12:618–628.[CrossRef][Web of Science][Medline]
  10. Höglund C., Alam M., Thorstrand C. Effects of acute myocardial infarction on the displacement of the atrioventricular plane: an echocardiographic study. J Intern Med (1989) 226:251–256.[Web of Science][Medline]
  11. Bach D.S., Armstrong W.F., Donovan C.L., Mulle D.W.M. Quantitative Doppler tissue imaging for assessment of regional myocardial velocities during transient ischemia and reperfusion. Am Heart J (1996) 132:721–725.[CrossRef][Web of Science][Medline]
  12. Bountioukos M., Schinkel A.F.L., Bax J.J., Rizzello V., Valkema R., Krenning B.J., et al. Pulsed wave tissue Doppler imaging for the quantification of contractile reserve in stunned, hibernating, and scarred myocardium. Heart (2004) 90:506–510.[Abstract/Free Full Text]
  13. Karwatowski S.P., Brecker S.J., Yang G.Z., Firmin D.N., St John Sutton M., Underwood S.R. A comparison of left ventricular myocardial velocity in diastole measured by magnetic resonance and left ventricular filling measured by Doppler echocardiography. Eur Heart J (1996) 17:795–802.[Abstract/Free Full Text]
  14. Sohn D.W., Chai I.H., Lee D.J., Kim H.C., Kim H.S., Oh B.H., et al. Assessment of mitral annular velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol (1997) 30:474–480.[Abstract]
  15. Ommen S.R., Nishimura R.A., Appleton C.P., Miller F.A., Oh J.K., Redfield M.M., et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures. A comparative simultaneous Doppler-catheterization study. Circulation (2000) 102:1788–1794.[Abstract/Free Full Text]

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