Evaluation of left ventricular diastolic function using an ambulatory radionuclide monitor: Relationship to left ventricular systolic performance Abnormalities of left ventricular (LV) filling may occur prior to systolic dysfunction in patients with both coronary and noncoronary heart disease. To determine the Incidence of diastolic dysfunction and to assess the relationship of such dysfunction to systolic performance, we measured systolic and diastolic function at rest in a series of healthy volunteers (n = 10) and in patients with cardiovascular disease (n = 42). Twenty patients had coronary artery disease (CAD) with prior myocardial infarction, six patients had CAD without myocardial infarction, and the remaining 16 patients had a variety of noncoronary heart diseases, including valvular heart disease, dilated cardiomyopathy, and hypertensive disease. The 42 patients manifested a wide variation in LV systolic function (ejection fractions ranged from 6% to 65%). Patients with reduced LV ejection fraction (EF) manifested a reduction in cardiac output and peak ejection rate proportionate to the reduction in EF. Diastolic function showed a fall in LV peak (PFR) and average (AFR) filling rates; these were reduced in proportion to the fall in EF. Heart rate was an insensitive index of the magnitude of fmpairment of LV systolic function. These data suggest that measurements of diastolic function do not provide additional information in patients with impaired systolic function. (AM HEART J 1990; 120:96.)
Masatoshi Nathaniel
Ishibashi, MD, PhD, Tsunehiro Yasuda, MD, Thomas P. ROCCO, MD, Alpert, PhD, Richard H. Moore, BS, and H. William Strauss, MD.
Boston, Mass.
Several recent studies implicate abnormal left ventricular (LV) diastolic function as a cause of congestive heart failure,ls3 even in the presence of normal systolic function. These reports suggest that abnormalities of relaxation may precede changes in contraction, and therefore may offer an advantage for the early detection or improved characterization of disease. Accordingly, efforts have focused on the development of noninvasive methods to determine the diastolic properties of the left ventricle. Noninvasive approaches to evaluate diastolic function have primarily used either Doppler echocardiography or radionuclide ventriculography4 to determine parameters such as the peak filling rate. To From the Department of Radiology, chusetts General Hospital. Received
9, 1990;
accepted
Medicine,
Feb.
15, 1990. of Nuclear
96
Jan.
of Nuclear
Reprint requests: H. William Strauss, MD, Division Massachusetts General Hospital, Boston, MA 02114. 4/I I20439
for publication
Division
Massa-
Medicine,
make this measurement with conventional gated blood pool scintigraphy requires a minimum temporal resolution of 40 msec/frame.5 Since few laboratories record data with this temporal resolution, diastolic parameters are rarely determined in clinical practice. Recently, a radionuclide device for the continuous monitoring of ventricular function was described6y 7 that records information from the cardiac blood pool with sufficient temporal resolution to permit the routine calculation of both systolic and diastolic parameters. 8, g The ambulatory ventricular function monitor (VEST)6* 7 has been used for the continuous monitoring of LV systolic functions-l0 in healthy subjects and in patients with coronary artery disease as they performed a variety of daily activities. The present study applied this instrument to monitoring cardiac function of subjects at rest. At the conclusion of blood pool imaging, about 3 minutes of data were recorded with the VEST to calculate various parameters of systolic and diastolic function.
Volume Number
120 1
LV diastolic
function
by ambulatory
scintigraphy
97
These data were used to determine the relationship of changes in systolic function to those of diastolic function in a series of patients with a variety of heart diseases. Methods Subjects.
The study population consistedof 42 patients (33 men and 9 women), aged 24 to 82 years (mean 61). Twenty patients had coronary artery disease(CAD) with prior myocardial infarction, six patients had CAD without myocardial infarction, six patients had valvular heart disease, five patients were pre- or post-doxorubiein (Adriamycin) administration, three patients had dilated cardiomyopathy, and two patients had high blood pressure.Patients were selected at random after undergoing routine radionuclide ventriculography. Ten volunteers aged 20 to 43 years (mean = 32 years) who were free of clinically apparent cardiopulmonary disease served as controls to establish the normal parameters of LV systolic and diastolic function. Fifteen of the 42 patients were taking medication within 43 hours of cardiac function measurement:one patient received a P-blocker, six patients received a calcium channel antagonist, and eight patients received both medications. The remaining 27 patients were not taking cardioactive medications at the time of examination. Radionuclide ventriculography. Multigated blood pool scanswere recorded about 10 minutes after intravenous administration of modified in vivo labeled autologousred cells (15 to 25 mCi of technetium-99m-pyrophosphate [99mTc].*l Gated blood pool data were acquired with a small field-of-view Anger camera equipped with an allpurpose parallel-hole collimator using a 20% window centered on the 99mTc photopeak. The data were recorded in a dedicated computer system using a 64 X 64 pixel matrix for 16 framesper cardiac cycle in the anterior, left anterior oblique, and left posterior oblique views for 10 minutes each. The LV ejection fraction was calculated from the background-corrected time-activity curve for comparison with and correlation to the VEST data. The VEST and detector positioning. The VEST consistsof two radionuclide detectors and the requisite electronics to perform energy discrimination and encode the signalsfor recording in parallel with two channelsof the electrocardiogram (ECG) on a Holter ECG recorder, as previously described.7-10 The VEST samplesand records data at 31 msecintervals. At the conclusion of the gated scan,the VEST detector waspositioned over the left ventricle using the persistence oscilloscopeof the scintillation camera (Fig. 1). An image with the VEST detector overlying the LV blood pool was recorded, and the detector was subsequentlysecuredwith Velcro tape. VEST data were acquired at rest for an average of 3.0 minutes in the supine position. The data were subsequently analyzed by a minicomputer (PDP 11/73, Digital Equipment Corp., Medical SystemsGroup, Marlboro, Mass.), as previously described.8*g
Fig. 1. End-diastolic blood pool imagein the left anterior oblique projection (left), before positioning with the main VEST detector, and after positioning the detector in the sameprojection (right).
Data analysis. The patients were divided into five groups based on their systolic function: ejection fraction >50%, 41% to 50%, 30% to 39%, 20% to 29%, and 100
1 00
and ejection fraction (EF) for all patients.
00
0
0 0
OO
0
0 0 0
al
I
00
0
00 1
O0 0
7
0
0 0 0
1
00 Y 0
OO
0 0 0
0
0’ Nor
1
2 Group
3
4
5
5. Relationship between early filling fraction and ejection fraction by group. Nor, Normal subjects, 1, EF > 50%; 2,50% I EF > 40%; 3,40% I EF > 30%; 4,30% L EF > 20%; 5, EF 2 20%. Fig.
lW0
Heart Journal
Volume Number
120 1
LV diastolic function by ambulatory scintigraphy
5 80 .--w 0 i!
0 0
60
0
l
.-F E 40
8 00
0 00
z ix
0
8
0
I
08
0
8 00
0 00
: 0
20
!
O0 0
00
0 Nor
1
f
0 0
2 Group
3
5
4
Fig. 6. Relationship betweenlate filling fraction and ejection fraction by group. Nor, Normal subjects;1,
EF > 50%; 2,50% ~40%; 3,40% 2 EF > 30%; 4,30% 1 EF > 20%; 5, EF I 20%.
6) 00 90 80 70 60 50 40
N=52 y=o.94x+5.37 R=0.90
30 20 10 o!
0
,
1
I
I
10
20
30
40
I
50
60
1
70
1
80
8
90
’
100
(%)
VEST-EF Fig.
7. Correlation between multiple gated acquisition (MUGA)-EF and VEST-EF in all patients.
101
102
Ishibashi
et al.
region of interest, while the scintillation camera data typically are gathered from a variable region of interest. The reliability of VEST data is dependent upon meticulous positioning of the VEST detector, with confirmation of detector localization by the scintillation camera. LV filling rates have been proposed as indices of ventricular compliance in contrast angiographic, radionuclide, and echocardiographic studies. Using conventional radionuclide-derived LV time-activity curves, Reduto et al. l7 found reduced peak filling rates in patients with CAD compared with normal subjects; however, a significant percentage of their CAD patients had impaired systolic function as a consequence of prior infarction. This resulted in a lower EF and a corresponding reduction of PFR, findings similar to our own. Bonaduce et al.l* reported that peak diastolic filling rate normalized to EDV is a useful index for identifying infarction patients; the lowest filling rate occurred in patients with reduced EF. Alternatively, Bonow et al.lg reported that the PFR of patients with CAD and normal LVEF was also reduced compared with that in normal subjects, implying a mechanism for PFR reduction independent of EF. We examined LV filling rates in relation to LVEF in 10 normal volunteers and in 42 patients with a variety of cardiovascular disorders. With respect to systolic performance, we found that LV peak ejection rate fell in proportion to the magnitude of impairment of LV systolic function. The effect of medication upon LV filling is variable. Fouad et a1.20 reported that the effects of ,&blockade on LV filling in hypertensive subjects were more apparent when not counterbalanced by a reduction in pressure load. Bonow21 reported that calcium channel antagonists favorably modify LV diastolic function by decreasing ischemia, effecting a salutary alteration of LV loading conditions, and/or by direct effects on myocardial relaxation. These investigators suggested that enhanced LV diastolic function is an important primary or secondary mechanism in the hypertrophied or ischemic left ventricle. Our data are consistent with prior studies in emphasizing the influence of LVEF on LV filling rates. An important observation was made regarding late filling; although previous studies have reported that atria1 filling fraction increases as early filling rates/filling fraction decrease, we were unable to identify this compensatory mechanism, even in patients with severe impairment of LV systolic performance. This suggests that mechanical atria1 systole is unable to increase contractile performance in the face of elevated LV diastolic pressures. It should be noted
American
July 1990 Heart Journal
that the magnitude of this impaired atria1 performance is obscure when filling fraction is expressed as a percentage of stroke counts, since stoke counts fall as progressive systolic dysfunction supervenes. Overall, our data support the contention that LVEF, the most important indication of global LV systolic function, is of fundamental importance to LV diastolic filling. REFERENCES
1. Smith VE, Schulman P, Karimeddini MK, White WB, Meeran MK, Katz AM. Rapid ventricular filling in left ventricularhypertrophy. II. Pathologic hypertrophy. J Am Co11 Cardiol 1985;5:869-74. 2. Top01 EJ, Tail1 TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 19851312:277-83. 3. Soufer R. Wohleerlenter D. Vita N. et al. Intact svstolic left ventricular function in clinical congestive heart failure. Am J Cardiol 1985;55:1032-6. 4. Friedman BJ, Drinkovic N, Miles H, Shih W, Mazzoleni A, Demaria AN. Assessment of left ventricular diastolic function: comparison of Doppler echocardiography and gated blood pool scintigraphy. J Am Co11 Cardiol 1986;8:1348-54. 5 Bacharach SL, Green MV, Borer JS, Hyde JE, Farkas SP, Johnston GS. Left-venticular peak ejection rate, filling rate, and ejection fraction-frame rate requirements at rest and execise:concise communication. J Nucl Med 1979;20:189-93. 6. Strauss HW, Lazewatsky J, Moore RH, Chaney R, Schriner R, McKusick KA. Entine G. Boucher CA. Pohost GM. The VEST: a device for the continuous monitoring of cardiac function in ambulatory patients Ihbstractl. Circulation 1979;59:11-246. I. Wilson RA, Sullivan PJ, Moore RH, Zielonka JS, Alpert NM, Boucher CA, Mckusick KA, Strauss HW. An ambulatory ventricular function monitor:validation and preliminary results. Am J Cardiol 1983;52:601-6. 8. Tamaki N, Gill JB, Moore RH, Yasuda T, Boucher CA, Strauss HW. Cardiac response to daily activities and exercise in normal subjects assessed by an ambulatory ventricular function monitor. Am J Cardiol 1987;59:1164-9. 9. Tamaki N, Yasuda T, Moore RH, Gill JB, Boucher CA, Hutter AM, Gold HK, Strauss HW. Continuous measurement of left ventricular function by an ambulatory monitor in patients with coronary disease. J Am Co11 Cardiol 1988;12:669-79. 10. Kiess MC, Dimsdale JE, Moore RH, Liu P, Newell M, BarlaiKovach M, Boucher CA, Strauss HW. The effects of stress on left ventricular ejection fraction. Eur J Nucl Med 1988;14: 12-6. 11. Callahan RJ, Froelich JW, McKusich KA, Leppo J, Strauss HW. A modified method for the in-vivo labeling of red blood cells with Tc-99m. J Nucl Med 1982;23:315-8. 12. Miller TR, Goldman KJ, Sampathkumaran KS, Biello DR, Ludhrock PA, Sobel BE. Analysis of cardiac diastolic function: application in coronary artery disease. J Nucl Med 1983;24:2-7. 13. Labovitz AJ, Pearson AC. Evaluation of left ventricular diastolic function: clinical relevance and recent Doppler echocardiographic insights. AM HEART J 1987;114:836-51. 14. Grossman W, Lore11 BH. Diastolic relaxation of the heart. Boston: Martinus Nijhoff Publishing, 1988:231-43. 15. Bonow RO, Frederick TM, Bacharach SL, Green MV, Goose PW, Maron BJ, Rosing DR. Atria1 systole and left ventricular filling in hypertrophic cardiomyopathy: effect of verapamil. Am J Cardiol 1983;51:1386-91. 16. Ishibashi M, Yasuda T, Strauss HW. Left ventricular diastolic filling in patients with varying degrees of left ventricular systolic dysfunction. [Abstract]. J Nucl Med 1989;30:868. 17. Reduto LA, Wickemeyer WJ, Young JB, Ventura LAD, Reid
Volume Number
17.0 1
LV diastolic function by ambulatory scintigraphy
JW, Glaeser DH, Quinones MA, Miller RR. Left ventricular diastolic performance at rest and during exercise in patients with coronary artery disease. Circulation 1981;63:1228-37. 18. Bonaduce D, Morgan0 G, Petretta M, Arrichiello P, Confort G, Betocchi S, Salvatore M, Chiariello M. Diastolic function in acute myocardial infarction: a radionuclide study. J Nucl Med 198&29:1786-g. 19. Bonow RO, Bacharach SL, Green MV, Kent KM, Rosing DR, Lipson LC, Leon MB, Epstein SE. Impaired left ventricular
diastolic filling in patients with coronary artery disease; assessment with radionuclide angiography. Circulation 1981; 64315-23. 20. Fouad FM, Soliminski MJ, Tarazi RC, Gallagher JH. Alterations in left ventricular filling with beta-adrenergenic blockade. Am J Cardiol 1983;51:161-4. 21. Bonow RO. Effects of calcium-channel blocking agents on left ventricular diastolic function in hypertrophic cardiomyopathy and in coronary artery disease. Am J Cardiol1985;55:172B-8B.
Altered systolic and diastolic function in children after “successful” repair of coarctation of the aorta We investigated whether left ventricular (LV) structural or functional abnormalities persist in children on long-term follow-up after successful correction of coarctation of the aorta. Two-dimensional directed M-mode and Doppler echocardlographic examinations were performed on 11 such subjects and 22 age-matched control subjects. Digftized tracings were made from M-mode recordings of the LV and Doppler mitral valve inflow recordings to measure septal, posterior wall, and LV dimensions, LV mass, shortening fraction, peak shortening and lengthening velocities, diastolic filling time, peak E velocity, peak A velocity, and velocity time integrals. Despite group simllarlties in age, body size, and systolic blood pressure, greater fractional shortening (p = O.OOOl), indexed peak shortening velocity fp < O.OOl), and greater LV mass index (p < 0.05) were seen in the coarctation group in the face of lower LV wall stress (p = 0.0001). LV mass index correlated with the resting arm-leg gradient, which ranged from -4 to +lO mm Hg. The coarctation group had decreased early filling (p < 0.006) with compensatory increased late diastolic filling (p < 0.05). Diastolic filling abnormallties were prominent in the older coarctation subjects and were related to both systolic blood pressure (p < 0.001) and LV mass index (p < 0.01). Despite apparently successful repair of coarctation of the aorta, persistent alterations in both systolic and diastolic LV function and LV mass are present in children at long-term follow-up, which are related to the resting arm-leg gradient. We speculate that these small measured arm-leg gradients represent persistent alterations in flow, which may result in LV hypertrophy and hyperkinesia. (AM HEART J 1990;120: 103.)
William Rodrigo
B. Moskowitz, MD, Richard M. Schieken, Bossano, MD. Richmond, Va.
MD, Michael
Increased rates of survival for children with coarctation of the aorta have resulted from both earlier intervention and improved surgical procedures.‘* 2 However, late cardiovascular morbidity and mortality continue to remain significant.3-5 The residual
From the Children’s Medical Medical College of Virginia. Received Reprint ology, 23298. 411120438
for publication
Center,
Oct. 30, 1989;
requests: William B. Moskowitz, Medical College of Virginia, Box
Division of Pediatric Cardiology, accepted
Feb.
20, 1990.
MD, Division of Pediatric Cardi543 MCV Station, Richmond, VA
Mosteller,
PhD, and
cardiovascular abnormalities include hypertension, recurrent coarctation, intracerebral aneurysm, and progressive calcific stenosis of an associated bicuspid aortic valve. Despite repair of coarctation of the aorta, there is a higher incidence of premature ischemic heart disease and sudden death. Left ventricular (LV) diastolic dysfunction has been described preoperatively in children with coarctation of the aorta.6 Results of echocardiographic and radionuclide studies show increased LV performance and persistent myocardial hypertrophy years after coarctation repair. 7, sThe purpose of the present study was to determine whether these preoperative 703
Masatoshi Nathaniel
Ishibashi, MD, PhD, Tsunehiro Yasuda, MD, Thomas P. ROCCO, MD, Alpert, PhD, Richard H. Moore, BS, and H. William Strauss, MD.
Boston, Mass.
Several recent studies implicate abnormal left ventricular (LV) diastolic function as a cause of congestive heart failure,ls3 even in the presence of normal systolic function. These reports suggest that abnormalities of relaxation may precede changes in contraction, and therefore may offer an advantage for the early detection or improved characterization of disease. Accordingly, efforts have focused on the development of noninvasive methods to determine the diastolic properties of the left ventricle. Noninvasive approaches to evaluate diastolic function have primarily used either Doppler echocardiography or radionuclide ventriculography4 to determine parameters such as the peak filling rate. To From the Department of Radiology, chusetts General Hospital. Received
9, 1990;
accepted
Medicine,
Feb.
15, 1990. of Nuclear
96
Jan.
of Nuclear
Reprint requests: H. William Strauss, MD, Division Massachusetts General Hospital, Boston, MA 02114. 4/I I20439
for publication
Division
Massa-
Medicine,
make this measurement with conventional gated blood pool scintigraphy requires a minimum temporal resolution of 40 msec/frame.5 Since few laboratories record data with this temporal resolution, diastolic parameters are rarely determined in clinical practice. Recently, a radionuclide device for the continuous monitoring of ventricular function was described6y 7 that records information from the cardiac blood pool with sufficient temporal resolution to permit the routine calculation of both systolic and diastolic parameters. 8, g The ambulatory ventricular function monitor (VEST)6* 7 has been used for the continuous monitoring of LV systolic functions-l0 in healthy subjects and in patients with coronary artery disease as they performed a variety of daily activities. The present study applied this instrument to monitoring cardiac function of subjects at rest. At the conclusion of blood pool imaging, about 3 minutes of data were recorded with the VEST to calculate various parameters of systolic and diastolic function.
Volume Number
120 1
LV diastolic
function
by ambulatory
scintigraphy
97
These data were used to determine the relationship of changes in systolic function to those of diastolic function in a series of patients with a variety of heart diseases. Methods Subjects.
The study population consistedof 42 patients (33 men and 9 women), aged 24 to 82 years (mean 61). Twenty patients had coronary artery disease(CAD) with prior myocardial infarction, six patients had CAD without myocardial infarction, six patients had valvular heart disease, five patients were pre- or post-doxorubiein (Adriamycin) administration, three patients had dilated cardiomyopathy, and two patients had high blood pressure.Patients were selected at random after undergoing routine radionuclide ventriculography. Ten volunteers aged 20 to 43 years (mean = 32 years) who were free of clinically apparent cardiopulmonary disease served as controls to establish the normal parameters of LV systolic and diastolic function. Fifteen of the 42 patients were taking medication within 43 hours of cardiac function measurement:one patient received a P-blocker, six patients received a calcium channel antagonist, and eight patients received both medications. The remaining 27 patients were not taking cardioactive medications at the time of examination. Radionuclide ventriculography. Multigated blood pool scanswere recorded about 10 minutes after intravenous administration of modified in vivo labeled autologousred cells (15 to 25 mCi of technetium-99m-pyrophosphate [99mTc].*l Gated blood pool data were acquired with a small field-of-view Anger camera equipped with an allpurpose parallel-hole collimator using a 20% window centered on the 99mTc photopeak. The data were recorded in a dedicated computer system using a 64 X 64 pixel matrix for 16 framesper cardiac cycle in the anterior, left anterior oblique, and left posterior oblique views for 10 minutes each. The LV ejection fraction was calculated from the background-corrected time-activity curve for comparison with and correlation to the VEST data. The VEST and detector positioning. The VEST consistsof two radionuclide detectors and the requisite electronics to perform energy discrimination and encode the signalsfor recording in parallel with two channelsof the electrocardiogram (ECG) on a Holter ECG recorder, as previously described.7-10 The VEST samplesand records data at 31 msecintervals. At the conclusion of the gated scan,the VEST detector waspositioned over the left ventricle using the persistence oscilloscopeof the scintillation camera (Fig. 1). An image with the VEST detector overlying the LV blood pool was recorded, and the detector was subsequentlysecuredwith Velcro tape. VEST data were acquired at rest for an average of 3.0 minutes in the supine position. The data were subsequently analyzed by a minicomputer (PDP 11/73, Digital Equipment Corp., Medical SystemsGroup, Marlboro, Mass.), as previously described.8*g
Fig. 1. End-diastolic blood pool imagein the left anterior oblique projection (left), before positioning with the main VEST detector, and after positioning the detector in the sameprojection (right).
Data analysis. The patients were divided into five groups based on their systolic function: ejection fraction >50%, 41% to 50%, 30% to 39%, 20% to 29%, and 100
1 00
and ejection fraction (EF) for all patients.
00
0
0 0
OO
0
0 0 0
al
I
00
0
00 1
O0 0
7
0
0 0 0
1
00 Y 0
OO
0 0 0
0
0’ Nor
1
2 Group
3
4
5
5. Relationship between early filling fraction and ejection fraction by group. Nor, Normal subjects, 1, EF > 50%; 2,50% I EF > 40%; 3,40% I EF > 30%; 4,30% L EF > 20%; 5, EF 2 20%. Fig.
lW0
Heart Journal
Volume Number
120 1
LV diastolic function by ambulatory scintigraphy
5 80 .--w 0 i!
0 0
60
0
l
.-F E 40
8 00
0 00
z ix
0
8
0
I
08
0
8 00
0 00
: 0
20
!
O0 0
00
0 Nor
1
f
0 0
2 Group
3
5
4
Fig. 6. Relationship betweenlate filling fraction and ejection fraction by group. Nor, Normal subjects;1,
EF > 50%; 2,50% ~40%; 3,40% 2 EF > 30%; 4,30% 1 EF > 20%; 5, EF I 20%.
6) 00 90 80 70 60 50 40
N=52 y=o.94x+5.37 R=0.90
30 20 10 o!
0
,
1
I
I
10
20
30
40
I
50
60
1
70
1
80
8
90
’
100
(%)
VEST-EF Fig.
7. Correlation between multiple gated acquisition (MUGA)-EF and VEST-EF in all patients.
101
102
Ishibashi
et al.
region of interest, while the scintillation camera data typically are gathered from a variable region of interest. The reliability of VEST data is dependent upon meticulous positioning of the VEST detector, with confirmation of detector localization by the scintillation camera. LV filling rates have been proposed as indices of ventricular compliance in contrast angiographic, radionuclide, and echocardiographic studies. Using conventional radionuclide-derived LV time-activity curves, Reduto et al. l7 found reduced peak filling rates in patients with CAD compared with normal subjects; however, a significant percentage of their CAD patients had impaired systolic function as a consequence of prior infarction. This resulted in a lower EF and a corresponding reduction of PFR, findings similar to our own. Bonaduce et al.l* reported that peak diastolic filling rate normalized to EDV is a useful index for identifying infarction patients; the lowest filling rate occurred in patients with reduced EF. Alternatively, Bonow et al.lg reported that the PFR of patients with CAD and normal LVEF was also reduced compared with that in normal subjects, implying a mechanism for PFR reduction independent of EF. We examined LV filling rates in relation to LVEF in 10 normal volunteers and in 42 patients with a variety of cardiovascular disorders. With respect to systolic performance, we found that LV peak ejection rate fell in proportion to the magnitude of impairment of LV systolic function. The effect of medication upon LV filling is variable. Fouad et a1.20 reported that the effects of ,&blockade on LV filling in hypertensive subjects were more apparent when not counterbalanced by a reduction in pressure load. Bonow21 reported that calcium channel antagonists favorably modify LV diastolic function by decreasing ischemia, effecting a salutary alteration of LV loading conditions, and/or by direct effects on myocardial relaxation. These investigators suggested that enhanced LV diastolic function is an important primary or secondary mechanism in the hypertrophied or ischemic left ventricle. Our data are consistent with prior studies in emphasizing the influence of LVEF on LV filling rates. An important observation was made regarding late filling; although previous studies have reported that atria1 filling fraction increases as early filling rates/filling fraction decrease, we were unable to identify this compensatory mechanism, even in patients with severe impairment of LV systolic performance. This suggests that mechanical atria1 systole is unable to increase contractile performance in the face of elevated LV diastolic pressures. It should be noted
American
July 1990 Heart Journal
that the magnitude of this impaired atria1 performance is obscure when filling fraction is expressed as a percentage of stroke counts, since stoke counts fall as progressive systolic dysfunction supervenes. Overall, our data support the contention that LVEF, the most important indication of global LV systolic function, is of fundamental importance to LV diastolic filling. REFERENCES
1. Smith VE, Schulman P, Karimeddini MK, White WB, Meeran MK, Katz AM. Rapid ventricular filling in left ventricularhypertrophy. II. Pathologic hypertrophy. J Am Co11 Cardiol 1985;5:869-74. 2. Top01 EJ, Tail1 TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 19851312:277-83. 3. Soufer R. Wohleerlenter D. Vita N. et al. Intact svstolic left ventricular function in clinical congestive heart failure. Am J Cardiol 1985;55:1032-6. 4. Friedman BJ, Drinkovic N, Miles H, Shih W, Mazzoleni A, Demaria AN. Assessment of left ventricular diastolic function: comparison of Doppler echocardiography and gated blood pool scintigraphy. J Am Co11 Cardiol 1986;8:1348-54. 5 Bacharach SL, Green MV, Borer JS, Hyde JE, Farkas SP, Johnston GS. Left-venticular peak ejection rate, filling rate, and ejection fraction-frame rate requirements at rest and execise:concise communication. J Nucl Med 1979;20:189-93. 6. Strauss HW, Lazewatsky J, Moore RH, Chaney R, Schriner R, McKusick KA. Entine G. Boucher CA. Pohost GM. The VEST: a device for the continuous monitoring of cardiac function in ambulatory patients Ihbstractl. Circulation 1979;59:11-246. I. Wilson RA, Sullivan PJ, Moore RH, Zielonka JS, Alpert NM, Boucher CA, Mckusick KA, Strauss HW. An ambulatory ventricular function monitor:validation and preliminary results. Am J Cardiol 1983;52:601-6. 8. Tamaki N, Gill JB, Moore RH, Yasuda T, Boucher CA, Strauss HW. Cardiac response to daily activities and exercise in normal subjects assessed by an ambulatory ventricular function monitor. Am J Cardiol 1987;59:1164-9. 9. Tamaki N, Yasuda T, Moore RH, Gill JB, Boucher CA, Hutter AM, Gold HK, Strauss HW. Continuous measurement of left ventricular function by an ambulatory monitor in patients with coronary disease. J Am Co11 Cardiol 1988;12:669-79. 10. Kiess MC, Dimsdale JE, Moore RH, Liu P, Newell M, BarlaiKovach M, Boucher CA, Strauss HW. The effects of stress on left ventricular ejection fraction. Eur J Nucl Med 1988;14: 12-6. 11. Callahan RJ, Froelich JW, McKusich KA, Leppo J, Strauss HW. A modified method for the in-vivo labeling of red blood cells with Tc-99m. J Nucl Med 1982;23:315-8. 12. Miller TR, Goldman KJ, Sampathkumaran KS, Biello DR, Ludhrock PA, Sobel BE. Analysis of cardiac diastolic function: application in coronary artery disease. J Nucl Med 1983;24:2-7. 13. Labovitz AJ, Pearson AC. Evaluation of left ventricular diastolic function: clinical relevance and recent Doppler echocardiographic insights. AM HEART J 1987;114:836-51. 14. Grossman W, Lore11 BH. Diastolic relaxation of the heart. Boston: Martinus Nijhoff Publishing, 1988:231-43. 15. Bonow RO, Frederick TM, Bacharach SL, Green MV, Goose PW, Maron BJ, Rosing DR. Atria1 systole and left ventricular filling in hypertrophic cardiomyopathy: effect of verapamil. Am J Cardiol 1983;51:1386-91. 16. Ishibashi M, Yasuda T, Strauss HW. Left ventricular diastolic filling in patients with varying degrees of left ventricular systolic dysfunction. [Abstract]. J Nucl Med 1989;30:868. 17. Reduto LA, Wickemeyer WJ, Young JB, Ventura LAD, Reid
Volume Number
17.0 1
LV diastolic function by ambulatory scintigraphy
JW, Glaeser DH, Quinones MA, Miller RR. Left ventricular diastolic performance at rest and during exercise in patients with coronary artery disease. Circulation 1981;63:1228-37. 18. Bonaduce D, Morgan0 G, Petretta M, Arrichiello P, Confort G, Betocchi S, Salvatore M, Chiariello M. Diastolic function in acute myocardial infarction: a radionuclide study. J Nucl Med 198&29:1786-g. 19. Bonow RO, Bacharach SL, Green MV, Kent KM, Rosing DR, Lipson LC, Leon MB, Epstein SE. Impaired left ventricular
diastolic filling in patients with coronary artery disease; assessment with radionuclide angiography. Circulation 1981; 64315-23. 20. Fouad FM, Soliminski MJ, Tarazi RC, Gallagher JH. Alterations in left ventricular filling with beta-adrenergenic blockade. Am J Cardiol 1983;51:161-4. 21. Bonow RO. Effects of calcium-channel blocking agents on left ventricular diastolic function in hypertrophic cardiomyopathy and in coronary artery disease. Am J Cardiol1985;55:172B-8B.
Altered systolic and diastolic function in children after “successful” repair of coarctation of the aorta We investigated whether left ventricular (LV) structural or functional abnormalities persist in children on long-term follow-up after successful correction of coarctation of the aorta. Two-dimensional directed M-mode and Doppler echocardlographic examinations were performed on 11 such subjects and 22 age-matched control subjects. Digftized tracings were made from M-mode recordings of the LV and Doppler mitral valve inflow recordings to measure septal, posterior wall, and LV dimensions, LV mass, shortening fraction, peak shortening and lengthening velocities, diastolic filling time, peak E velocity, peak A velocity, and velocity time integrals. Despite group simllarlties in age, body size, and systolic blood pressure, greater fractional shortening (p = O.OOOl), indexed peak shortening velocity fp < O.OOl), and greater LV mass index (p < 0.05) were seen in the coarctation group in the face of lower LV wall stress (p = 0.0001). LV mass index correlated with the resting arm-leg gradient, which ranged from -4 to +lO mm Hg. The coarctation group had decreased early filling (p < 0.006) with compensatory increased late diastolic filling (p < 0.05). Diastolic filling abnormallties were prominent in the older coarctation subjects and were related to both systolic blood pressure (p < 0.001) and LV mass index (p < 0.01). Despite apparently successful repair of coarctation of the aorta, persistent alterations in both systolic and diastolic LV function and LV mass are present in children at long-term follow-up, which are related to the resting arm-leg gradient. We speculate that these small measured arm-leg gradients represent persistent alterations in flow, which may result in LV hypertrophy and hyperkinesia. (AM HEART J 1990;120: 103.)
William Rodrigo
B. Moskowitz, MD, Richard M. Schieken, Bossano, MD. Richmond, Va.
MD, Michael
Increased rates of survival for children with coarctation of the aorta have resulted from both earlier intervention and improved surgical procedures.‘* 2 However, late cardiovascular morbidity and mortality continue to remain significant.3-5 The residual
From the Children’s Medical Medical College of Virginia. Received Reprint ology, 23298. 411120438
for publication
Center,
Oct. 30, 1989;
requests: William B. Moskowitz, Medical College of Virginia, Box
Division of Pediatric Cardiology, accepted
Feb.
20, 1990.
MD, Division of Pediatric Cardi543 MCV Station, Richmond, VA
Mosteller,
PhD, and
cardiovascular abnormalities include hypertension, recurrent coarctation, intracerebral aneurysm, and progressive calcific stenosis of an associated bicuspid aortic valve. Despite repair of coarctation of the aorta, there is a higher incidence of premature ischemic heart disease and sudden death. Left ventricular (LV) diastolic dysfunction has been described preoperatively in children with coarctation of the aorta.6 Results of echocardiographic and radionuclide studies show increased LV performance and persistent myocardial hypertrophy years after coarctation repair. 7, sThe purpose of the present study was to determine whether these preoperative 703
