| Background and ObjectiveAtrial fibrillation is usually associated with congestive heart failure, especially in the elderly population. Study found that congestive heart failure is a common cause of death in patients with heart disease, and about a third of congestive heart failure in patients with left ventricular systolic function is normal, then left ventricular diastolic function insufficiency can lead to left ventricular ejection ejection fraction(LVEF) normal incidence in patients with congestive heart failure reasons. In addition, atrial fibrillation is also an indicator of poor prognosis in patients with congestive heart failure. Although the importance of left ventricular diastolic function in patients with atrial fibrillation and heart failure has been well recognized, noninvasive examination of left ventricular diastolic function in many patients is still limited.E/e ’, TE-e’ measured by echocardiography is a good predictor of left ventricular filling pressure. The measurement of E and e’ values can not be completed in the same cardiac cycle, which is affected by the factors such as heart rate, heart rate, respiration, and so on. It has great difference in numerical value and poor accuracy. Accurate measurement is not performed in patients with cardiac arrhythmias, which limits the clinical application of these techniques in the evaluation of left ventricular diastolic function.Simultaneous doppler can be used to measure the data of E/e ’and TE-e’ in the same cardiac cycle, which has the advantages of accurate and reliable. Especially for patients with atrial fibrillation,the value of E/e ’and TSE-e’ of single cardiac cycle measured by dual Doppler echocardiography has the advantage of high accuracy. In this study,we evaluate the feasibility and clinical usefulness of TSE–e’, the time interval between the onset of early transmitral flow velocity(E) and that of early diastolic mitral annular velocity(e’), obtained by simultaneous doppler tracing E and e’, in terms of evaluating diastolic function. Methods1. 44 patients(27 men; mean age, 61±14 years) with non-valvular atrial fibrillation during 2014 to 2015 December in our hospital hospitalization were evaluated, conforms to the 2010 European Society of Cardiology(ESC) atrial fibrillation treatment guidelines in any a type history of atrial fibrillation. Exclusion of left ventricular ejection fraction less than 50%, mitral stenosis, severe mitral regurgitation, previously prosthetic valve implantation, infection endocarditis, severe bleeding tendency, congenital heart disease, recently implanted pacing catheter was completely left bundle branch block, primary or secondary cardiomyopathy, right heart function, kidney function not and pericardial disease patients. Can not cooperate with ultrasound examination, image acquisition failure or poor quality of imaging.2.The Hitachi hi vision preirus color Doppler ultrasonic diagnostic apparatus, probe S70-A, probe frequency 2-4MHz, for two-dimensional, M-mode and Doppler ultrasound echocardiography.3. Conventional echocardiography: before the examination all normal subjects were measured height, weight, blood pressure, heart rate. Take the left lateral decubitus position, calm breathing, is connected with the synchronous ECG and parasternal left ventricular long axis view were measured by conventional ultrasound indicators: left atrial diameter(LAD), left ventricular diastolic end diastolic diameter(LVEDD), interventricular septal thickness(IVSD), and left ventricular posterior wall thickness(PWD), left ventricular end diastolic volume index(LVEDVI) was calculated by LVEDVI = LVEDV / BSA. The left ventricular ejection fraction(LVEF) was obtained by Teichholz method. In apical five chamber view of the heart, the pulse Doppler sampling line placed in mitral valve and left ventricular outflow tract, left ventricular inflow and outflow tract blood flow frequency spectrum, measuring left ventricular isovolumic diastolic isovolumic relaxation time(IVRT). For conventional TE-e’(TCE-e’) calculations, time intervals were measured between peak R waves and the onsets of E, and between peak R waves and onsets of e’. Every RR interval corresponding to each time interval measurement was also measured. Cases incapable of obtaining the cardiac cycles with the difference of RR interval <50 ms were excluded from TCE-e’ analysis.Dual Doppler synchronous sampling technique for the detection of: in the apical four chamber view of the heart, open PW/TDI synchronous sampling technique, the sample volume were placed in the mitral valve and mitral valve annulus, and recording of mitral valve flow spectrum and mitral valve side wall flap ring tissue Doppler spectrum, a cardiac cycle measurements of diastolic early mitral blood flow peak velocity E(cm / s), deceleration time(deceleration time DT), mitral valve side wall annulus diastolic peak velocity of early e’(cm / s), calculated with a cardiac cycle E / e’ ratio, peak E and e’ peak start time difference TSE-e’. All patients were performed by the same physician, storage 3 cardiac cycle measurements from 3 cardiac cycles of average value.5.Hemodynamic Measurements: using Swan Ganz balloon floating catheter that was introduced through the right internal jugular vein via a percutaneous approach, floating into the right atrium, right ventricle and wedge block to parts of small pulmonary arteries, blocking the premises before into the blood stream. The tip of catheter measured pressure is pulmonary artery wedge pressure(PAWP), also called pulmonary capillary wedge pressure(PCWP). Based on the measured by Swan Ganz catheter pulmonary capillary wedge pressure(PCWP) all the enrolled patients were randomly divided into two groups(A, B): group A: PCWP is less than or equal to 12 mm Hg(n = 23); group B: PCWP >12mm Hg(n = 21). There was no significant difference in the sex composition, blood pressure and BSA between the two groups(P > 0.05). Results1.Subject baseline characteristics and 2-D Echocardiographic ParametersAccording to the measured by Swan Ganz catheter pulmonary capillary wedge pressure(PCWP) all enrolled patients were divided into two groups: PCWP is less than or equal to 12 mm Hg(n = 23) group and PCWP > mm Hg(n = 21) group. There was no significant difference in the sex composition, blood pressure and BSA between the two groups(p > 0.05). Conventional echocardiography measured value comparison between the two groups of left ventricular diastolic end diastolic diameter(LVEDd), interventricular septal thickness(IVSD), left ventricular posterior wall thickness(LVPDW), left ventricular diastolic end diastolic volume index(LVEDVI), left atrial diameter(LAD) arithmetic different had no statistical significance(p>0.05). But the age and left ventricular ejection fraction(LVEF) increased(p<0.05) in the group PCWP > 12 mm Hg.2. Correlation between conventional Doppler Parameters and dual Doppler ParametersPCWP > 12 mmhg group and PCWP≤12 mm Hg group comparison: early diastolic mitral flow peak velocity(E) higher diastolic early mitral annulus peak velocity(e’) lower, peak e deceleration time(DT) and isovolumic relaxation time(IVRT) extend, TCE-e’, TSE-e ’significantly prolonged, the E / e’ significantly increased(p < 0.05).3.Correlation analysisA moderate correlation was showed between TCE-e’ and TSE-e’, r = 0.55, p<0.001. A good correlation was showed between E/e ’and TSE-e’, r = 0.78, p<0.001. E/e ’and TCE-e’ have moderate correlation, r = 0.48, p=0.001.The correlation between Pulmonary capillary wedge pressure(PCWP) and E/e’ is good, r=0.69, p < 0.001. The correlation between PCWP with TSE-e’ and TCE-e’ was r = 0.79, p < 0.001 and p < 0.001, r = 0.58 p<0.001, respectively.4.Receiver Operating Characteristic Curve AnalysisA cut-off of >11.4 for E/e’ predicted a PCWP of >12mm Hg, with 90% sensitivity and 74% specificity. The area under the ROC curve using E/e’ to differentiate PCWP >12mm Hg from that of ≤12mm Hg was 0.87. If the cut-off for TCE–e’ was set at >24 ms, the sensitivity and specificity of the prediction of PCWP >12 mm Hg were 85% and 66%, respectively. The area under the ROC curve using TCE–e’ to differentiate PCWP>12mm Hg from that of ≤12mm Hg was 0.80.The cut-off for TCE–e’ was set at >22 ms, the sensitivity and specificity of the prediction of PCWP >12 mm Hg were 90% and 92%, respectively. The area under the ROC curve using TSE–e’ to differentiate PCWP>12mm Hg from that of ≤12mm Hg was 0.90. The combined criteria of TSE–e’ >22ms and E/e’ >11.4 produced 100% sensitivity and 83% specificity for detecting PCWP>12mm Hg.The area under the ROC curve using TCE–e’ to differentiate PCWP>12mm Hg from that of ≤12mm Hg was 0.93. Conclusion1.Significant relationships were observed between PCWP and dual Doppler E/e’、TSE-e’。2.If the cut-off for TE–e’ was set at >22 ms, the sensitivity and specificity of the prediction of PCWP >12 mm Hg were 90% and 92%, respectively. A cut-off of >11.4 for E/e’ predicted a PCWP >12mm Hg, with 90% sensitivity and 74% specificity.3.The combined criteria of TE–e’≥ 22 ms and E/e’ ≥ 11.4 produced 100% sensitivity and 83% specificity for detecting PCWP >12mm Hg.4.Simultaneous measurement of E/e’、TSE-e’ is feasible and clinically applicable for estimating diastolic dysfunction in patients with non-valvular atrial fibrillation,and the combination of the two can further improve the accuracy of evaluation of left ventricular filling pressure. |
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