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Which indexes of filling behavior should be used to characterize left ventricular diastolic function when changes in
T E Meyer1, B Casadei, G P Aurigemma
1Department of Cardiovascular Medicine, John Radcliffe Hospital, Worcester, MA, USA.
Insights
This study found that the ratio of the square root of diastolic filling period to RR interval or functional cycle length is a reliable index for assessing left ventricular diastolic function, independent of heart rate and atrioventricular delay.
Area of Science:
- Cardiology
- Physiology
- Biomedical Engineering
Background:
- Standard mitral velocity ratios are limited by heart rate and atrioventricular delay.
- Previous methods struggle to accurately assess left ventricular diastolic function under varying physiological conditions.
Purpose of the Study:
- To normalize mitral velocity ratios for heart rate and atrioventricular delay.
- To identify a reliable index for left ventricular diastolic function independent of confounding factors.
Main Methods:
- Evaluated ratios in 18 patients with dual-chamber pacemakers under altered heart rate and atrioventricular delay.
- Utilized isoproterenol and methoxamine infusions to modify left ventricular filling.
- Assessed various mitral velocity profile parameters and their normalization strategies.
Main Results:
- Early velocity integral ratios were sensitive to heart rate and atrioventricular delay variations.
- The peak early-to-peak atrial velocity ratio showed reduced sensitivity to heart rate when normalized by RR interval or diastolic filling period.
- The ratio of the square root of diastolic filling period to RR interval or functional cycle length proved independent of heart rate and atrioventricular delay.
Conclusions:
- The ratio of the square root of diastolic filling period to RR interval or functional cycle length is a robust index for left ventricular diastolic function.
- This novel ratio effectively differentiates true changes in diastolic function from alterations caused by heart rate and atrioventricular delay.
Abstract:
The routine use of the peak early-to-peak atrial velocity, early velocity integral-to-atrial velocity integral, and early velocity integral-to-the total filling velocity integral ratios are limited because they are influenced by heart rate and atrioventricular delay. Hence, we sought to establish whether these ratios could be normalized to account for the differences in cycle length (RR interval) and diastolic filling period when heart rate and atrioventricular delay were altered in 18 patients with programmable dual-chamber pacemakers. We further explored whether these and other parameters of the mitral velocity profile could be used to characterize the mitral filling pattern during isoproterenol and methoxamine infusions-interventions that are likely to change both heart rate and left ventricular filling. The early velocity integral-to-atrial velocity integral and early velocity integral-to-the total filling velocity integral ratios were more sensitive to minor variations in heart rate and atrioventricular delay than the peak early-to-peak atrial velocity ratio. The early velocity integral-to-atrial velocity integral and early velocity integral-to-total filling velocity integral ratios could not be normalized to account for differences in RR interval or diastolic filling period, whereas the peak early-to-peak atrial velocity ratio became less sensitive to changes in heart rate when it was divided by the RR interval, or diastolic filling period, or square root of diastolic filling period. Because the diastolic filling period is affected by atrioventricular delay independent of changes in the RR interval, these ratios were also corrected for the functional cycle length, defined as the interval from R-wave of the electrocardiogram to the end of the diastolic filling period. When corrected for either the functional cycle length or diastolic filling period or square root of diastolic filling period, only the peak early-to-peak atrial velocity ratio became less sensitive to variations in the atrioventricular delay. The ratio of diastolic filling period expressed as a proportion of RR interval or functional cycle length changed significantly when heart rate and atrioventricular delay were altered and did not improve when diastolic filling period was divided by the square root of RR or square root of functional cycle length. However, when the square root of diastolic filling period was divided by the RR interval or functional cycle length, the effects of heart rate and atrioventricular delay were not apparent. Of all the ratios, the ratio of square root of diastolic filling period expressed as a proportion of RR interval or functional cycle length was the most useful to differentiate the confounding effects of heart rate (+/-atrioventricular delay) from the effects of isoproterenol and methoxamine on left ventricular filling. Hence, this ratio appeared to be a heart rate- and atrioventricular delay-independent index of left ventricular diastolic function.