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Diastolic dysfunction in an unusual case of cardiomyopathy in a child: insights from Doppler and Doppler tissue imaging analysis.

OBJECTIVES: This case report describes an unusual form of cardiomyopathy in a child with abnormalities in both ventricular relaxation and compliance. The diastolic abnormalities are well-defined using Doppler inflow velocities and Doppler tissue imaging, and the Doppler findings are correlated with intracardiac pressure measurements. This case illustrates the use of noninvasive Doppler techniques in identifying diastolic dysfunction, and it sheds additional light on the interplay of relaxation, compliance, and heart rate in creating the variable inflow Doppler patterns encountered clinically.

Cardiomyopathy, Hypertrophic↗

Lack of effect of short-term lisinopril administration on left ventricular filling dynamics in hypertensive patients with diastolic dysfunction.

Arterial hypertension may be associated with altered left ventricular filling dynamics. The specific goal of this study was to evaluate whether short-term administration of the ACE inhibitor lisinopril in hypertensive patients with an altered diastolic pattern induced an improvement of left ventricular dynamics, assessed by the echocardio-Doppler technique, independently of effects on left ventricular mass. In a double-blind cross-over study 39 essential hypertensive patients with a ratio of peak early to peak atrial velocity (E/A) < 1 were randomized, after a run-in period of 2 weeks without any antihypertensive treatment, to receive lisinopril (20 mg once a day) and placebo for 4 weeks, respectively. At the end of both the run-in and the treatment periods, blood pressure and heart rate were measured and an echocardio-Doppler examination was carried out. The echocardio-Doppler evaluation was performed both at rest and at the peak of a hand-grip test (3 min at 30% of maximal strength). Left ventricular dimensions were obtained from two-dimensionally guided M-mode tracings using the criteria of the American Society of Echocardiography. Left ventricular peak filling rates and filling rate integrals were measured by a pulsed Doppler technique. Lisinopril caused a significant reduction in systolic and diastolic blood pressure at rest (-13/-9 mmHg vs baseline values, p < 0.05; -6/-4 mmHg vs placebo values, p < 0.05) and during isometric exercise (-17/-9 mmHg vs baseline period, p < 0.05; -6/-5 mmHg vs placebo, p < 0.05). Lisinopril did not induce any significant change in left ventricular structure and systolic function. All the left ventricular filling parameters considered (E velocity, A velocity, E/A ratio) both at rest and during isometric exercise did not significantly differ after lisinopril treatment when compared to those obtained in basal conditions and after placebo administration. This double-blind cross-over study demonstrates that short-term afterload reduction induced by lisinopril does not modify altered diastolic dynamics in hypertensive patients. Diastolic dysfunction of the left ventricle is a complex process influenced by a number of functional and structural factors and apparently cannot be significantly improved by short-term blood pressure reduction by antihypertensive therapy.

Angiotensin-Converting Enzyme Inhibitors↗

From hypertension to heart failure: update on the management of systolic and diastolic dysfunction.

The aging of the population of the United States (US) will bring with it higher numbers of patients with coronary heart disease and heart failure (HF). Because HF already imposes severe economic and medical burdens on our health care system, it is imperative to optimize primary and secondary prevention of cardiovascular (CV) disease. In most cases, HF develops as a result of either long-standing hypertension or a myocardial infarction (MI). Other than cardiac death, HF represents the last stage in the progression of CV disease, which begins with CV risk factors such as hypertension, dyslipidemia, obesity, and smoking. These risk factors lead to the development of left ventricular (LV) hypertrophy or an MI (or both), which lead to LV dysfunction and, finally, to HF. The prognosis of HF is poor, the 5-year survival rate being approximately 25%. Heart failure may be due to either LV systolic or diastolic dysfunction, the latter having a normal ejection fraction. Because CV disease is progressive, interventions are possible at all stages along the CV continuum. Beta-blockers (betaB) are recommended agents at several stages of CV disease. Large-scale trials have shown that betaB significantly reduce risks for morbidity and mortality in patients with HF. Ongoing studies should help to clarify further the optimal cardioprotective therapies in patients with HF.

Adrenergic beta-Antagonists↗

Load-independent index of diastolic filling: model-based derivation with in vivo validation in control and diastolic dysfunction subjects.

Maximum elastance is an experimentally validated, load-independent systolic function index stemming from the time-varying elastance paradigm that decoupled extrinsic load from (intrinsic) contractility. Although Doppler echocardiography is the preferred method of diastolic function (DF) assessment, all echo-derived indexes are load dependent, and no invasive or noninvasive load-independent index of filling (LIIF) exists. In this study, we derived and experimentally validated a LIIF. We used a kinematic filling paradigm (the parameterized diastolic filling formalism) to predict and derive the (dimensionless) dynamic diastolic efficiency M, defined by the slope of the peak driving force [maximum driving force (kx(o)) proportional, variant peak atrioventricular (AV) gradient] to maximum viscoelastic resistive force [peak resistive force (cE(peak))] relation. To validate load independence, we analyzed E-waves recorded while load was varied via tilt table (head up, horizontal, and head down) in 16 healthy volunteers. For the group, linear regression of E-wave derived kx(o) vs. cE(peak) yielded kx(o) = M (cE(peak)) + B, r2 = 0.98; where M = 1.27 +/- 0.09 and B = 5.69 +/- 1.70. Effects of diastolic dysfunction (DD) on M were assessed by analysis of preexisting simultaneous cath-echo data in six DD vs. five control subjects. Average M for the DD group (M = 0.98 +/- 0.07) was significantly lower than controls (M = 1.17 +/- 0.05, P < 0.001). We conclude that M is a LIIF because it uncouples intrinsic DF (i.e., the pressure-flow relation) from extrinsic load (left ventricular end-diastolic pressure). Larger M values imply better DF in that increasing AV pressure gradient results in relatively smaller increases in peak resistive losses (cE(peak)). Conversely, lower M implies that increasing AV gradient leads to larger increases in resistive losses. Further prospective validation characterizing M in well-defined pathological states is warranted.

Adult↗

In vivo infusion of oxygen free radical substrates causes myocardial systolic, but not diastolic dysfunction.

Contractile dysfunction of viable, previously ischemic stunned myocardium is thought to be due to reactive oxygen species generated during ischemia/reperfusion. Direct in vivo evidence that oxidants cause systolic or diastolic dysfunction of viable myocardium has, however, been lacking. We sought to determine whether in vivo exposure of canine myocardium to exogenously generated reactive oxygen species could--in the absence of myocardial ischemia or necrosis--"mimic" the depressed systolic contractile function, paradoxical contraction during early diastole, and prolonged diastolic relaxation time characteristic of stunned myocardium. Anesthetized open-chest dogs were randomly assigned to receive either (1) the free radical generating substrates xanthine oxidase + purine + iron-saturated transferrin or (2) saline, infused directly into an anterior coronary vein. Infusion of free radical substrates did not cause ischemia: regional myocardial blood flow and myocardial high-energy phosphate stores were normal in both groups. Furthermore, infusion of xanthine oxidase + purine + transferrin was not associated with histologic or electron microscopic evidence of myocyte injury or death in this model. Xanthine oxidase + purine + transferrin did, however, produce marked abnormalities in regional systolic contractile function; at 2 hours after the onset of infusion, segment shortening (assessed by sonomicrometry) in the perfused region of the heart averaged 62 +/- 5% of baseline, preinfusion values in animals infused with free radical substrates versus 113 +/- 8% of baseline values in saline-administered control dogs (p less than 0.004). This systolic dysfunction was effectively reversed by administration of the free radical scavenging agents superoxide dismutase + catalase.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Effects of amlodipine and lacidipine on heart rate variability in hypertensive patients with stable angina pectoris and isolated left ventricular diastolic dysfunction.

OBJECTIVE: To estimate the influence of therapy with amlodipine (A) or lacidipine (L) on heart rate variability (HRV) time and frequency domain parameters in hypertensive patients with stable angina pectoris and isolated left ventricular diastolic dysfunction. METHODS: After a 1-week washout period, the patients were randomized to receive amlodipine 10 mg (30 patients) or lacidipine 6 mg (30 patients) once-daily for 4 weeks. HRV parameters were determined over a period of 24 h, echocardiography and exercise test were performed before and after treatment. RESULTS: All HRV time domain parameters after applying amlodipine did not change significantly. A reliable decrease only of the root mean square of differences between adjacent normal-to-normal intervals (RMSSD)-32.9 +/- 13 vs. 27.5 +/- 9-was noticed after treatment with lacidipine. In the lacidipine group, the change of RMSSD negatively correlated with the extent of ST segment depression during exercise testing (R = -0.43; P < 0.05). Both drugs reduced total power (A, 2234 +/- 1270 vs. 1813 +/- 889; L, 2205 +/- 1151 vs. 1825 +/- 896; P < 0.01), very low (A, 1451 +/- 733 vs. 1143 +/- 534; L, 1413 +/- 759 vs. 1213 +/- 616; P < 0.05), and low frequency power (A, 610 +/- 459 vs. 447 +/- 321; L, 569 +/- 323 vs. 442 +/- 241; P < 0.01). After amlodipine, high frequency power remained unchanged, whereas low-high frequency ratio decreased (4.54 +/- 1.72 vs. 3.77+/-1.73; P < 0.05). After lacidipine, high frequency power decreased (178.8 +/- 153.2 vs. 132.1 +/- 79.3; P < 0.05), whereas the ratio of low frequency to high frequency did not change. CONCLUSIONS: Amlodipine and lacidipine reduce the influence of humoral control and sympathetic autonomic nervous system activity. The autonomic balance becomes shifted toward the increased vagal activity only by amlodipine.

Adult↗

Infusion of light chains from patients with cardiac amyloidosis causes diastolic dysfunction in isolated mouse hearts.

BACKGROUND: Primary (AL) amyloidosis is a plasma cell dyscrasia characterized by clonal production of immunoglobulin light chains (LC) resulting in the subsequent systemic deposition of extracellular amyloid fibrils. Cardiac involvement is marked by the hemodynamic pattern of impaired diastolic filling and restrictive cardiomyopathy. Although cardiac death in patients with AL amyloidosis is usually associated with extensive myocardial infiltration, the infiltration alone does not correlated with the degree of heart failure or survival. We hypothesized that circulating monoclonal LC may directly impair cardiac function, in addition to any mechanical effects of amyloid fibril deposition. Therefore, we examined the effects of amyloid LC proteins on diastolic and systolic cardiac function, as measured in an isolated mouse heart model. METHODS AND RESULTS: LC were obtained from patients with nonamyloid disease or from those with noncardiac, mild cardiac, and severe cardiac involved AL amyloidosis. Saline or LC (100 microgram/mL) was infused into a Langendorff-perfused, isovolumically contracting mouse heart. Saline and control, noncardiac, and mild-cardiac LC infusions did not alter ex vivo cardiac function. In contrast, infusion of sever cardiac LC resulted in marked impairment of ventricular relaxation with preservation of contractile function. CONCLUSION: These results demonstrate that infusion of LC from patients with AL amyloidosis result in diastolic dysfunction similar to that observed in patients with cardiac involved AL amyloidosis, and they suggest that amyloid LC proteins may contribute directly to the pathogenesis and the rapid progression of amyloid cardiomyopathy, independent of extracellular fibril deposition.

Amyloidosis↗

Late left ventricular color M-mode Doppler in the assessment of diastolic dysfunction in patients with dilated cardiomyopathy.

The ratio of early (Ep) to late (Ap) color M-mode Doppler flow propagation through the left ventricle helps in the differentiation between normal and pseudonormal (PSN) filling pattern in patients with preserved systolic function. We studied the value of this index in the assessment of diastolic dysfunction for patients with reduced left ventricular systolic function. We studied 80 patients with nonischemic dilated cardiomyopathy and 50 control subjects. According to echocardiography 53 patients had abnormal relaxation and 27 had PSN pattern. Patients had reduced Ep (P < .001) and Ep/Ap ratio (P < .001) and increased Ap (P = .001) compared to controls. Binary logistic regression analysis showed that Ep followed by Ep/Ap ratio (both P < .001) were the best determinants for the discrimination of PSN from normal filling pattern. Ep/Ap ratio, this novel echo-index, increases the diagnostic accuracy of color M-mode Doppler in discriminating normal from PSN filling pattern in patients with left ventricular systolic dysfunction.

Cardiomyopathy, Dilated↗

Coronary vasospasm-induced acute diastolic dysfunction in a patient with Raynaud's phenomenon.

We present the case of a patient with severe dyspnea and Raynaud's phenomenon. We could clarify, using invasive techniques including left ventricular conductance catheterization and coronary ergonovine provocation, that isolated diastolic dysfunction induced by coronary vasospasm were responsible for the symptoms. Systolic function was not affected. Short-term infusions with the prostacyclin analogue iloprost, known to act as a disease-modifying agent in patients suffering from Raynaud's phenomenon, led to an improvement of cardiac function. Thus, episodes of dyspnea in patients with Raynaud's phenomenon might be also interpreted as a coronary ischemia equivalent, which may belong to a visceral form of Raynaud's phenomenon and which are sensitive to iloprost infusions.

Coronary Vasospasm↗

Diastolic dysfunction in normotensive men with well-controlled type 2 diabetes: importance of maneuvers in echocardiographic screening for preclinical diabetic cardiomyopathy.

OBJECTIVE: Because a pseudonormal pattern of ventricular filling has never been considered in studies that reported a prevalence of left ventricular diastolic dysfunction (LVDD) between 20 and 40%, our aim was to more completely evaluate the prevalence of LVDD in subjects with diabetes. RESEARCH DESIGN AND METHODS: We studied 46 men with type 2 diabetes who were aged 38-67 years; without evidence of diabetic complications, hypertension, coronary artery disease, congestive heart failure, or thyroid or overt renal disease; and with a maximal treadmill exercise test showing no ischemia. LVDD was evaluated by Doppler echocardiography, which included the use of the Valsalva maneuver and pulmonary venous recordings to unmask a pseudonormal pattern of left ventricular filling. RESULTS: LVDD was found in 28 subjects (60%), of whom 13 (28%) had a pseudonormal pattern of ventricular filling and 15 (32%) had impaired relaxation. Systolic function was normal in all subjects, and there was no correlation between LVDD and indexes of metabolic control. CONCLUSIONS: LVDD is much more common than previously reported in subjects with well-controlled type 2 diabetes who are free of clinically detectable heart disease. The high prevalence of this phenomenon in this high-risk population suggests that screening for LVDD in type 2 diabetes should include procedures such as the Valsalva maneuver and pulmonary venous recordings to unmask a pseudonormal pattern of ventricular filling.

Adult↗

Prevalence of left ventricular diastolic dysfunction in obese persons with and without diabetes mellitus.

Forty obese diabetic patients (mean age 48 +/- 9 years) and 93 obese nondiabetic patients (mean age 43 +/- 9 years) underwent Doppler and tissue Doppler echocardiographic evaluation of left ventricular diastolic function before gastric bypass surgery. Moderate or severe left ventricular diastolic dysfunction was present in 24 of 40 obese diabetics (60%) and in 21 of 93 obese nondiabetics (23%) (p <0.001).

Adult↗

Moderate calorie restriction improves cardiac remodeling and diastolic dysfunction in the Dahl-SS rat.

Caloric restriction extends longevity and reduces the onset of chronic disease in many animal models. Recently, caloric restriction was shown in humans to be associated with lower blood pressure, decreased systemic inflammation, and improved cardiac diastolic parameters. However, the causation and mechanisms of caloric restriction were obscured by the varied diet composition of the participants. The Dahl salt-sensitive rat which develops gradual, hypertension-associated diastolic dysfunction was used in this study to assess the impact of caloric restriction upon decompensated pressure-overload hypertrophy. Male Dahl salt-sensitive rats were provided either a low-salt diet or a high-salt diet to initiate heart failure progression. A further subset of high-salt rats underwent 15% calorie restriction, with salt load held constant. Parameters measured included serial systolic blood pressure, body weight, and changes of left ventricular systolic and diastolic parameters and ventricular geometry by echocardiography. After 18 weeks, fasting glucose, blood lipids, heart weight, kidney weight, lung weight, plasma interleukin-6 and TNF-alpha, and cardiac lipid peroxidation were measured. Low-salt rats did not develop heart failure. While high-salt rats displayed features of decompensated pressure-overload hypertrophy, moderate calorie restriction remarkably reduced morbidity. Compared to the high-salt fed group, the high-salt, calorie-restricted group showed reduced blood pressure, delayed onset of cachexia, lower fasting hyperlipidemia, lower cardiac, renal and lung weight, less plasma IL-6 and TNF-alpha, less cardiac oxidative damage, and improved diastolic chamber function and cardiac index. Modest calorie restriction, independent of salt intake, reduced pathogenesis in this well described model of decompensated pressure-overload hypertrophy.

Animals↗

Cardiac systolic and diastolic dysfunction after a cholesterol-rich diet.

BACKGROUND: Although hypercholesterolemia is a well-established risk factor for coronary artery disease, little is known regarding its direct effects on cardiac function. METHODS AND RESULTS: We examined the effects of cholesterol feeding (0.5%) on cardiac function in rabbits. After 10 weeks, both systolic shortening and diastolic relaxation rates were impaired without any change in aortic pressure or ventricular hypertrophy. However, sarcoplasmic/endoplasmic reticulum Ca2+-ATPase (SERCA)-2 mRNA levels were reduced within 4 days after initiation of cholesterol feeding. After this effect, SERCA-2 protein and SERCA-mediated Ca uptake into sarcoplasmic reticulum vesicles were impaired, and the ratio of MHC-beta to MHC-alpha mRNA increased 5-fold. Suppression of the SERCA-2 message correlated temporally with enrichment of the cardiac sarcolemma with cholesterol. CONCLUSIONS: These data demonstrate that dietary hypercholesterolemia induces a "cholesterol cardiomyopathy" characterized by systolic and diastolic dysfunction. These alterations were independent of vascular disease and demonstrate a dietary link to cardiac dysfunction.

Animals↗

Left-ventricular diastolic dysfunction may be prevented by chronic treatment with PPAR-alpha or -gamma agonists in a type 2 diabetic animal model.

OBJECTIVES: The aim of this study was to determine whether the peroxisome proliferator-activated receptor (PPAR) ligands could prevent left-ventricular diastolic dysfunction (LVDD) in rats with advanced diabetes. In addition, this study examined whether the activity of malonyl-CoA decarboxylase (MCD), which is an enzyme related to the degradation of malonyl-CoA that is known to regulate the fatty acid metabolism, is changed by the diabetic state itself or by treatment with the PPAR ligands. METHODS: Male Otsuka Long-Evans Tokushima Fatty (OLETF) rats, a model of type 2 diabetes, aged 28 weeks, were divided into 3 groups: the untreated, pioglitazone-treated (10 mg/kg/d), and fenofibrate-treated (150 mg/kg/d) groups. The rats were treated for 10 weeks. Male Long-Evans Tokushima Otsuka (LETO) rats were used as nondiabetic control. Doppler echocardiography and measurements of the MCD activity at the myocardium were performed. RESULTS: At the age of 38 weeks, the OLETF rats treated with either pioglitazone or fenofibrate showed an improvement in the plasma glucose levels after glucose loading as well as an improvement in the fasting plasma insulin, triglyceride, and FFA levels compared to the untreated OLETF rats. The untreated OLETF rats showed a prolonged deceleration time of the E-wave (DTE) (74.3 +/- 3.7 vs LETO, 56.3 +/- 3.8 ms, P < 0.05) and a reduced ratio of the peak early diastolic velocity wave to the late diastolic wave (E/A ratio) (1.25 +/- 0.06 vs LETO 1.54 +/- 0.08, P < 0.05). Pioglitazone treatment in the OLETF rats improved the DTE (51.6 +/- 1.7 ms, P < 0.05), and the fenofibrate treatment also improved the DTE (61.4 +/- 4.3 ms, P < 0.05) and E/A ratio (1.57 +/- 0.05, P < 0.05) compared to the untreated OLETF rats. The parameters related to the systolic function did not change among the groups at both pre- and post-treatments. The MCD activity of the myocardium was remarkably lower in the OLETF rats compared to the LETO rats (3.26 +/- 0.38 vs 7.76 +/- 0.84 nmol/min/mg protein, P < 0.05). The pioglitazone and fenofibrate treatments resulted in an increase in the MCD activity compared to that in the untreated rats (7.20 +/- 0.74 and 8.33 +/- 0.83 nmol/min/mg protein, P < 0.05, respectively). CONCLUSIONS: The PPAR-alpha or -gamma agonists prevented LVDD in the advanced diabetic rat hearts, possibly through an improvement in the fatty acid metabolism in the myocardium or a correction of the hyperglycemia and/or hyperlipidemia.

Animals↗

[Role of left ventricular systolic and diastolic dysfunction in clinical manifestations of chronic heart failure in patients with prior myocardial infarction].

AIM: To study the impact of systolic and systolic dysfunction of the left ventricle (LV) on the clinical manifestations of chronic heart failure (HF) in patients with prior myocardial infarction (MI). MATERIALS AND METHODS: 102 patients (mean age 47.4 +/- 0.7 years) who had sustained large focal IM at least 6 months before were examined. LV echocardiography was made to define systolic-diastolic relationships in HF. RESULTS: Analyzing the prevalence of primary diastolic HF in patients with its different clinical manifestations, it may be concluded that LV diastolic dysfunction is of the leading pathogenetic value at early stages of ischemic heart dysfunction. A complex relationship between the clinical manifestations of HF and a number of parameters characterizing the systolic and diastolic function of LV was estimated by the multiple regression analysis and presented as a trinomial equation. CONCLUSION: The results of the regression analysis have shown that the clinical manifestation of HF intensifies as relaxation slows down and transmitral blood flow redistributes to the left atrial systole; the severity of HF also increases with the depletion of compensatory mechanisms responsible for LV contractility.

Diastole↗

Left ventricular diastolic dysfunction in congenital chronic anaemias during childhood as determined by comprehensive echocardiographic imaging including acoustic quantification.

AIMS: To evaluate prospectively the left ventricular performance in thalassaemia major and sickle cell disease using comprehensive echocardiographic imaging including acoustic quantification during early childhood. METHODS AND RESULTS: Twenty-three patients with thalassaemia and 26 patients with sickle cell disease underwent echocardiographic examination including M-mode, 2-D, Doppler and acoustic quantification. All patients were matched for age, sex, weight and height with 20 normal controls. All patients were below 13 years of age. Thalassaemia and sickle cell disease patients were significantly anaemic when compared with normals (P<0.0001). All patients had normal left ventricular systolic parameters. Acoustic quantification-derived left ventricular volumes, filling rates, and emptying rates were not different in thalassaemia patients from controls. Left ventricular volumes, however, were larger in sickle cell disease patients than in controls. In contrast, by Doppler technique, left ventricular filling occurs mainly in early diastole (E wave) in thalassaemia patients and mainly in late diastole (A wave) in sickle cell disease patients, (P=0.03 and 0.01 respectively). E/A ratio was lower and diastolic filling period was shorter than normal in sickle cell disease but not in thalassaemia patients. Patients in both groups had left ventricular mass (determined by M-mode) significantly higher than normal (P<0.0001). CONCLUSION: The left ventricular systolic performance is well preserved in patients with chronic anaemia due to thalassaemia major and sickle cell disease during early childhood. In both diseases, however, there is left ventricular hypertrophy and measurable abnormalities in the diastolic filling detected by Doppler. Such changes do not fit a specific cardiomyopathic pattern due to diastolic dysfunction i.e. restrictive physiology vs delayed relaxation. Acoustic quantification of left ventricular diastolic parameters (filling rates) was less sensitive than Doppler in detecting these early diastolic abnormalities in both diseases.

Acoustics↗

[Hemodynamics in heart failure: systolic and diastolic dysfunction].

Cardiac insufficiency is hemodynamically characterised by reduced cardiac output and increased diastolic filling pressure at rest and/or during physical activity. The increase in diastolic filling pressure compensates cardiac output and is either a result of increased initial tension of muscle fibers (Frank-Starling's Law) or a sign of decreased myocardial compliance. Increased initial tension of muscle fibers is a sign of systolic insufficiency, whereas reduced ventricular compliance indicates a disorder of diastolic ventricular function. In systolic insufficiency (= systolic dysfunction) a decrease in the ventricular ejection fraction is important, as is an increase in filling pressure. In diastolic congestive heart failure (= diastolic dysfunction) a reduced ventricular compliance with normal stroke function is typical.

Diastole↗