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. 1992 Dec;68(6):567–573. doi: 10.1136/hrt.68.12.567

Relation of left ventricular isovolumic relaxation time and incoordination to transmitral Doppler filling patterns

Stephen J D Brecker 1, Chiang H Lee 1, Derek G Gibson 1
PMCID: PMC1025686  PMID: 1467050

Abstract

Objective—To investigate factors during isovolumic relaxation that determine Doppler filling patterns in patients with left ventricular disease, and thus to identify the underlying mechanisms.

Design—85 patients (50 ischaemic heart disease, 35 left ventricular hypertrophy due to aortic stenosis) and 26 controls were studied with Doppler and M mode echocardiography and phonocardiography. 16 patients underwent two studies on separate occasions, to find whether changes in isovolumic relaxation time were reflected by a change in the Doppler A/E ratio.

Setting—A tertiary cardiac referral centre.

Subjects—Patients referred for assessment of coronary artery disease or aorticstenosis with left ventricular hypertrophy.

Main outcomes measures—Doppler filling velocities during early (E wave) and late (A wave) diastole and the A/E ratio, acceleration of the E wave, digitised M mode indices of incoordinate relaxation (change in cavity dimension before mitral valve opening and time from minimum dimension to mitral valve opening), isovolumic relaxation time, M mode measures of diastolic function after mitral valve opening (peak rate of posterior wall thinning and peak rate of dimension increase), and left ventricular end diastolic pressure.

Results—A/E correlated with age in normal subjects (r = 0·74), to a lesser extent in left ventricular hypertrophy (r = 0·41), but not significantly in ischaemic heart disease. In all patients, isovolumic relaxation time was significantly and negatively correlated with the acceleration of the E wave, showing its fundamental relation to the force responsible for early diastolic filling (r = −0·71 for left ventricular hypertrophy, and −0·74 for ischaemic heart disease, p value < 0·01). In left ventricular hypertrophy and those ischaemic patients without left ventricular dilatation A/E was correlated both with isovolumic relaxation time (r = 0·68 and 0·60 respectively), and with incoordinate relaxation (r = 0·65 and 0·61). In those ischaemic patients with left ventricular dilatation, the influence of incoordination was lost and isovolumic relaxation time became the dominant influence upon A/E (r = 0·82). Weak correlations of end diastolic pressure and RR interval with A/E, became insignificant once isovolumic relaxation time had been taken into account. Isovolumic relaxation time and incoordination together accounted for over 50% of the variance in the A/E ratio in our patients. Isovolumic relaxation time and the A/E ratio were linearly related. Patients with a short isovolumic relaxation time had evidence of considerable diastolic abnormalities, despite a normal Doppler A/E ratio. In the 16 patients who had two echocardiographic studies, changes in the duration of isovolumic relaxation were accompanied by a change in the Doppler A/E ratio. The relation between these two variables, derived from the group as a whole was similar.

Conclusions—The main factors influencing the A/E ratio in patients with left ventricular disease are two distinct properties of isovolumic relaxation—namely the duration and the extent of incoordinate wall motion. Filling pressure and RR interval are not significant independent determinants, but act only through an effect upon isovolumic relaxation time. Age is an important influence in normal people, but this effect is attenuated in left ventricular hypertrophy and lost in ischaemic ventricular disease.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bryg R. J., Williams G. A., Labovitz A. J. Effect of aging on left ventricular diastolic filling in normal subjects. Am J Cardiol. 1987 Apr 15;59(9):971–974. doi: 10.1016/0002-9149(87)91136-2. [DOI] [PubMed] [Google Scholar]
  2. Castello R., Pearson A. C., Kern M. J., Labovitz A. J. Diastolic function in patients undergoing coronary angioplasty: influence of degree of revascularization. J Am Coll Cardiol. 1990 Jun;15(7):1564–1569. doi: 10.1016/0735-1097(90)92827-o. [DOI] [PubMed] [Google Scholar]
  3. Channer K. S., Culling W., Wilde P., Jones J. V. Estimation of left ventricular end-diastolic pressure by pulsed Doppler ultrasound. Lancet. 1986 May 3;1(8488):1005–1007. doi: 10.1016/s0140-6736(86)91273-0. [DOI] [PubMed] [Google Scholar]
  4. Choong C. Y., Abascal V. M., Thomas J. D., Guerrero J. L., McGlew S., Weyman A. E. Combined influence of ventricular loading and relaxation on the transmitral flow velocity profile in dogs measured by Doppler echocardiography. Circulation. 1988 Sep;78(3):672–683. doi: 10.1161/01.cir.78.3.672. [DOI] [PubMed] [Google Scholar]
  5. Choong C. Y., Herrmann H. C., Weyman A. E., Fifer M. A. Preload dependence of Doppler-derived indexes of left ventricular diastolic function in humans. J Am Coll Cardiol. 1987 Oct;10(4):800–808. doi: 10.1016/s0735-1097(87)80273-5. [DOI] [PubMed] [Google Scholar]
  6. Doran J. H., Traill T. A., Brown D. J., Gibson D. G. Detection of abnormal left ventricular wall movement during isovolumic contraction and early relaxation. Comparison of echo- and angiocardiography. Br Heart J. 1978 Apr;40(4):367–371. doi: 10.1136/hrt.40.4.367. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Ettles D. F., Davies J., Williams G. J. Can left ventricular end-diastolic pressure be estimated non-invasively? Int J Cardiol. 1988 Aug;20(2):239–245. doi: 10.1016/0167-5273(88)90268-9. [DOI] [PubMed] [Google Scholar]
  8. Fioretti P., Brower R. W., Meester G. T., Serruys P. W. Interaction of left ventricular relaxation and filling during early diastole in human subjects. Am J Cardiol. 1980 Aug;46(2):197–203. doi: 10.1016/0002-9149(80)90058-2. [DOI] [PubMed] [Google Scholar]
  9. Gibson D. G., Brown D. Measurement of instantaneous left ventricular dimension and filling rate in man, using echocardiography. Br Heart J. 1973 Nov;35(11):1141–1149. doi: 10.1136/hrt.35.11.1141. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Gibson D. G., Doran J. H., Traill T. A., Brown D. J. Abnormal left ventricular wall movement during early systole in patients with angina pectoris. Br Heart J. 1978 Jul;40(7):758–766. doi: 10.1136/hrt.40.7.758. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Gibson D. G., Prewitt T. A., Brown D. J. Analysis of left ventricular wall movement during isovolumic relaxation and its relation to coronary artery disease. Br Heart J. 1976 Oct;38(10):1010–1019. doi: 10.1136/hrt.38.10.1010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Hui W. K., Gibson D. G. Mechanisms of reduced left ventricular filling rate in coronary artery disease. Br Heart J. 1983 Oct;50(4):362–371. doi: 10.1136/hrt.50.4.362. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Ishida Y., Meisner J. S., Tsujioka K., Gallo J. I., Yoran C., Frater R. W., Yellin E. L. Left ventricular filling dynamics: influence of left ventricular relaxation and left atrial pressure. Circulation. 1986 Jul;74(1):187–196. doi: 10.1161/01.cir.74.1.187. [DOI] [PubMed] [Google Scholar]
  14. Klewer S. E., Goldberg S. J., Donnerstein R. L., Berg R. A., Hutter J. J., Jr Dobutamine stress echocardiography: a sensitive indicator of diminished myocardial function in asymptomatic doxorubicin-treated long-term survivors of childhood cancer. J Am Coll Cardiol. 1992 Feb;19(2):394–401. doi: 10.1016/0735-1097(92)90497-b. [DOI] [PubMed] [Google Scholar]
  15. Kuecherer H., Ruffmann K., Kuebler W. Determination of left ventricular filling parameters by pulsed Doppler echocardiography: a noninvasive method to predict high filling pressures in patients with coronary artery disease. Am Heart J. 1988 Oct;116(4):1017–1021. doi: 10.1016/0002-8703(88)90153-6. [DOI] [PubMed] [Google Scholar]
  16. Kuo L. C., Quinones M. A., Rokey R., Sartori M., Abinader E. G., Zoghbi W. A. Quantification of atrial contribution to left ventricular filling by pulsed Doppler echocardiography and the effect of age in normal and diseased hearts. Am J Cardiol. 1987 May 1;59(12):1174–1178. doi: 10.1016/0002-9149(87)90870-8. [DOI] [PubMed] [Google Scholar]
  17. Lee C. H., Hogan J. C., Gibson D. G. Diastolic disease in left ventricular hypertrophy: comparison of M mode and Doppler echocardiography for the assessment of rapid ventricular filling. Br Heart J. 1991 Apr;65(4):194–200. doi: 10.1136/hrt.65.4.194. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Lee C. H., Vancheri F., Josen M. S., Gibson D. G. Discrepancies in the measurement of isovolumic relaxation time: a study comparing M mode and Doppler echocardiography. Br Heart J. 1990 Sep;64(3):214–218. doi: 10.1136/hrt.64.3.214. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Marino P., Destro G., Barbieri E., Zardini P. Early left ventricular filling: an approach to its multifactorial nature using a combined hemodynamic-Doppler technique. Am Heart J. 1991 Jul;122(1 Pt 1):132–141. doi: 10.1016/0002-8703(91)90770-i. [DOI] [PubMed] [Google Scholar]
  20. Mattheos M., Shapiro E., Oldershaw P. J., Sacchetti R., Gibson D. G. Non-invasive assessment of changes in left ventricular relaxation by combined phono-, echo-, and mechanocardiography. Br Heart J. 1982 Mar;47(3):253–260. doi: 10.1136/hrt.47.3.253. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Miyatake K., Okamoto M., Kinoshita N., Owa M., Nakasone I., Sakakibara H., Nimura Y. Augmentation of atrial contribution to left ventricular inflow with aging as assessed by intracardiac Doppler flowmetry. Am J Cardiol. 1984 Feb 1;53(4):586–589. doi: 10.1016/0002-9149(84)90035-3. [DOI] [PubMed] [Google Scholar]
  22. Ng K. S., Gibson D. G. Relation of filling pattern to diastolic function in severe left ventricular disease. Br Heart J. 1990 Apr;63(4):209–214. doi: 10.1136/hrt.63.4.209. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Nikolić S., Yellin E. L., Tamura K., Vetter H., Tamura T., Meisner J. S., Frater R. W. Passive properties of canine left ventricle: diastolic stiffness and restoring forces. Circ Res. 1988 Jun;62(6):1210–1222. doi: 10.1161/01.res.62.6.1210. [DOI] [PubMed] [Google Scholar]
  24. Nishimura R. A., Abel M. D., Hatle L. K., Holmes D. R., Jr, Housmans P. R., Ritman E. L., Tajik A. J. Significance of Doppler indices of diastolic filling of the left ventricle: comparison with invasive hemodynamics in a canine model. Am Heart J. 1989 Dec;118(6):1248–1258. doi: 10.1016/0002-8703(89)90017-3. [DOI] [PubMed] [Google Scholar]
  25. Nishimura R. A., Abel M. D., Hatle L. K., Tajik A. J. Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clin Proc. 1989 Feb;64(2):181–204. doi: 10.1016/s0025-6196(12)65673-0. [DOI] [PubMed] [Google Scholar]
  26. Park C. H., Chow W. H., Gibson D. G. Phase differences between left ventricular wall motion and transmitral flow in man: evidence for involvement of ventricular restoring forces in normal rapid filling. Int J Cardiol. 1989 Sep;24(3):347–354. doi: 10.1016/0167-5273(89)90014-4. [DOI] [PubMed] [Google Scholar]
  27. Sanderson J. E., Gibson D. G., Brown D. J., Goodwin J. F. Left ventricular filling in hypertrophic cardiomyopathy. An angiographic study. Br Heart J. 1977 Jun;39(6):661–670. doi: 10.1136/hrt.39.6.661. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Stoddard M. F., Pearson A. C., Kern M. J., Ratcliff J., Mrosek D. G., Labovitz A. J. Influence of alteration in preload on the pattern of left ventricular diastolic filling as assessed by Doppler echocardiography in humans. Circulation. 1989 Jun;79(6):1226–1236. doi: 10.1161/01.cir.79.6.1226. [DOI] [PubMed] [Google Scholar]
  29. Stoddard M. F., Pearson A. C., Kern M. J., Ratcliff J., Mrosek D. G., Labovitz A. J. Left ventricular diastolic function: comparison of pulsed Doppler echocardiographic and hemodynamic indexes in subjects with and without coronary artery disease. J Am Coll Cardiol. 1989 Feb;13(2):327–336. doi: 10.1016/0735-1097(89)90507-x. [DOI] [PubMed] [Google Scholar]
  30. Störk T. V., Müller R. M., Piske G. J., Ewert C. O., Hochrein H. Noninvasive measurement of left ventricular filling pressures by means of transmitral pulsed Doppler ultrasound. Am J Cardiol. 1989 Sep 15;64(10):655–660. doi: 10.1016/0002-9149(89)90497-9. [DOI] [PubMed] [Google Scholar]
  31. Takagi S., Yokota M., Iwase M., Yoshida J., Hayashi H., Sotobata I., Koide M., Saito H. The important role of left ventricular relaxation and left atrial pressure in the left ventricular filling velocity profile. Am Heart J. 1989 Nov;118(5 Pt 1):954–962. doi: 10.1016/0002-8703(89)90230-5. [DOI] [PubMed] [Google Scholar]
  32. Xiao H. B., Lee C. H., Gibson D. G. Effect of left bundle branch block on diastolic function in dilated cardiomyopathy. Br Heart J. 1991 Dec;66(6):443–447. doi: 10.1136/hrt.66.6.443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Yellin E. L., Nikolic S., Frater R. W. Left ventricular filling dynamics and diastolic function. Prog Cardiovasc Dis. 1990 Jan-Feb;32(4):247–271. doi: 10.1016/0033-0620(90)90016-u. [DOI] [PubMed] [Google Scholar]

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