Preface

Echocardiography, despite the huge development of computed tomography and magnetic resonance imaging, is still the most used imaging technique for the evaluation of cardiac anatomy and function and today it plays an essential role in daily decision making.

Echocardiography offers a number of advantages over newer and more sophisticated technologies. First of all echocardiography offers a complete morphological and hemody‐ namic evaluation. Furthermore ultrasounds are radiation and contrast free, they are wide‐ ly available, relatively cheap and they can be performed at the patient's bed, even to very critical ones.

Cardiologists face unique challenges interpreting echocardiographic imaging and trough the integration of these data with other clinical information.

Heart failure is becoming increasingly common and a major clinical and public health challenge. The prevalence of the disease is rising mainly because the population is getting older. More people survive myocardial infarction and some of them will develop heart failure. An increasing fraction, especially older, diabetic, hypertensive patients, and those with atrial fibrillation, exhibit heart failure with preserved systolic function. Echocardiog‐ raphy meets the growing need for non-invasive imaging in the expanding heart failure population because of its ability to provide accurate measures of ventricular function, fill‐ ing pressure and to asses causes of structural heart disease. Echocardiography offers also prognostic information and can guide the therapy.

The echocardiographic technology and its applications have widely developed in the last years leading to a better diagnostic accuracy. On the other hand echocardiography special‐ ists have new clinical questions to answer.

Since the introduction of percutaneous closure of patent foramen ovale, atrial and ventric‐ ular septal defects, echocardiography has become the imaging technique of choice in selec‐ tion of patients and during the percutaneous procedure in the cath lab.

In the last years new structural heart interventions have become widely available such as, transcatheter aortic valve replacement, mitral valve repair, mitral valvuloplasty and left atrial appendage closure. These new percutaneous therapies need, in particular during the patients selection phase, a precise evaluation of cardiac dimensions and a complete under‐ standing of the spatial relationships between cardiac structures. Echocardiography is of paramount importance both during the patient evaluation and guiding the procedure.

Three dimensional echocardiography, especially in the transesophageal approach, is a key technique for a precise localization and an easier definition of cardiac anatomy.

#### VIII Preface

This book tries to give an in depth evaluation about the specific issues that a modern car‐ diovascular imaging specialist is asked to answer nowadays.

#### **Dr. Angelo Squeri**

**Chapter 1**

**Echocardiographic Evaluation**

Junichi Yoshikawa and Minoru Yoshiyama

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55619

diastolic heart failure approaches 50%.[3-5]

diastolic function with echocardiography.

the contrary a mechanical property of the myocardial wall.

**1. Introduction**

important.

**of Left Ventricular Diastolic Function**

Ryotaro Wake, Shota Fukuda, Hiroki Oe, Yukio Abe,

The mortality, hospitalization, and prevalence rates of heart failure (HF) are increasing, in spite

Approximately half of patients with a diagnosis of heart failure have a normal left ventricular (LV) ejection fraction (EF) without valve disease which is defined as diastolic heart failure (DHF), because it is attributed to LV diastolic dysfunction.[2] Studies examining prevalence of diastolic heart failure in hospitalized patients or in patients undergoing outpatient diag‐ nostic screening and prospective community based studies have shown that the prevalence of

They tend to be older and female, and their condition is likely to be associated with hyperten‐ sion, diabetes mellitus and ischemic heart disease. Many reports show that the mortality and morbidity of DHF is minimal differences from that of HF with a reduced EF. Moreover, although the mortality and morbidity have improved for patients with HF with a reduced EF, it has not changed for patients with DHF. So, the Evaluation of LV diastolic function is

LV diastolic function is related to myocardial relaxation and passive LV properties and is modulated myocardial tone. Myocardial relaxation is an active process, while stiffness is on

Echocardiography is useful for the evaluation of LV diastolic function. The points of diastolic function to be estimated with echocardiography are propagation velocities, pulmonary vein Doppler, mitral inflow pattern and tissue Doppler imaging. We discuss the estimation of LV

> © 2013 Wake et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

of decrease in coronary artery and cerebrovascular disease mortality.[1]

Cardiology Maria Cecilia Hospital, Cotignola (RA) Italy

### **Chapter 1**

### **Echocardiographic Evaluation of Left Ventricular Diastolic Function**

Ryotaro Wake, Shota Fukuda, Hiroki Oe, Yukio Abe, Junichi Yoshikawa and Minoru Yoshiyama

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55619

#### **1. Introduction**

This book tries to give an in depth evaluation about the specific issues that a modern car‐

**Dr. Angelo Squeri**

Maria Cecilia Hospital, Cotignola (RA)

Cardiology

Italy

diovascular imaging specialist is asked to answer nowadays.

VIII Preface

The mortality, hospitalization, and prevalence rates of heart failure (HF) are increasing, in spite of decrease in coronary artery and cerebrovascular disease mortality.[1]

Approximately half of patients with a diagnosis of heart failure have a normal left ventricular (LV) ejection fraction (EF) without valve disease which is defined as diastolic heart failure (DHF), because it is attributed to LV diastolic dysfunction.[2] Studies examining prevalence of diastolic heart failure in hospitalized patients or in patients undergoing outpatient diag‐ nostic screening and prospective community based studies have shown that the prevalence of diastolic heart failure approaches 50%.[3-5]

They tend to be older and female, and their condition is likely to be associated with hyperten‐ sion, diabetes mellitus and ischemic heart disease. Many reports show that the mortality and morbidity of DHF is minimal differences from that of HF with a reduced EF. Moreover, although the mortality and morbidity have improved for patients with HF with a reduced EF, it has not changed for patients with DHF. So, the Evaluation of LV diastolic function is important.

LV diastolic function is related to myocardial relaxation and passive LV properties and is modulated myocardial tone. Myocardial relaxation is an active process, while stiffness is on the contrary a mechanical property of the myocardial wall.

Echocardiography is useful for the evaluation of LV diastolic function. The points of diastolic function to be estimated with echocardiography are propagation velocities, pulmonary vein Doppler, mitral inflow pattern and tissue Doppler imaging. We discuss the estimation of LV diastolic function with echocardiography.

### **2. The mechanism of DHF**

Heart failure is a clinical syndrome characterized by symptoms and signs of increased tissue water and decreased tissue perfusion. Definition of the mechanisms that cause this clinical syndrome requires measurement of both systolic and diastolic function. When heart failure is accompanied by a predominant or isolated abnormality in diastolic function, this clinical syndrome is called diastolic heart failure. The pathophysiology is attributed to LV diastolic dysfunction, in which LV diastolic chamber size is normal or reduced despite elevated filling pressures resulting in decreased cardiac output. DHF occurs when the ventricular chamber is unable to accept an adequate volume of blood during diastole, because of a decrease in ventricular relaxation and/or an increase in ventricular stiffness,[2] and increased circulating blood volume is present. Hypertension, ischemia, aging and diabetes mellitus are the major risk factor of a decrease in ventricular relaxation and/or an increase in ventricular stiffness. Endocardial biopsies from HF patients without coronary artery disease (CAD) showed structural and functional differences in cardiomyocytes from patients with diastolic HF compared to cardiomyocytes from patients with abnormal systolic ejection fraction.[6] Myocytes from patients with diastolic HF had increased diameter and higher myofibrillar density and developed greater passive force and had greater calcium sensitivity. Myocardial collagen volume fraction was equally elevated.

than 100 pg/mL, any form of heart failure is virtually ruled out because of the high negative predictive value of the natriuretic peptides, and pulmonary disease becomes the most likely

Echocardiographic Evaluation of Left Ventricular Diastolic Function

http://dx.doi.org/10.5772/55619

3

As far as diastolic dysfunction, in decompensated patients with advanced systolic heart failure (LVEF≦30%, New York Heart Association class III to IV symptoms), tissue Doppler-derived with E/E' ratio may not be as reliable in predicting intracardiac filling pressures, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac

Comprehensive Doppler echocardiography is invaluable in the evaluation of HF patients. It is established that the mitral E wave velocity reflects the LA-LV pressure gradient during early diastole and is therefore affected by preload and alterations in LV relaxation. Assessment of diastolic function begins with the transmitral flow velocity profile. Decreases in the ratio of early to late diastolic filling (E/A), increases in the deceleration time, increases in the isovolumic relaxation time, or increases in tissue Doppler imagings (E/E') indicate impaired relaxation. However, in the presence of impaired relaxation, increases in filling pressure progressively modify the transmitral gradient and mitral inflow pattern. A comprehensive Doppler assess‐ ment must be used to determine diastolic function from filling pressures and tissue Doppler imagings. [10] Patients studied at various times during their presentation will display a spectrum of filling patterns, including abnormal relaxation and psuedonormal or restrictive patterns. Such a spectrum has also been reported in patients with HF with a depressed EF and reflects the potent effect of filling pressures and blood pressure and their interaction with underlying diastolic dysfunction on the Doppler patterns. Thus, depending on their level of compensation and their filling pressures and whether they have exertional or rest symptoms,

Tissue Doppler imaging (TDI) is performed in the apical views to acquire mitral annular velocities with pulse wave. The sample volume should be positioned at 1 cm within the septal and lateral insertion sites of the mitral leaflets. It is recommended that spectral recordings be obtained at a sweep speed of 50 to 100 mm/s at end-expiration and that measurements should reflect the average of more than 3 consecutive cardiac cycles. Primary measurements include the systolic and early (e') and late (a') diastolic velocities. For the assessment of global LV diastolic function, it is recommended to acquire and measure tissue Doppler signals at least at the septal and lateral sides of the mitral annulus and their average. In patients with cardiac disease, e' can be used to correct for the effect of LV relaxation on mitral E velocity, and the E/ e' ratio can be applied for the prediction of LV filling pressures. The E/e' ratio is not accurate as an index of filling pressures in normal subjects or in patients with heavy annular calcifica‐

*2.2.1. Doppler echocardiographic assessment of diastolic function and filling pressures*

patients with HFpEF may display any of the filling patterns.[12]

tion, mitral valve disease, and constrictive pericarditis.

cause of breathlessness. [9, 10]

resynchronization therapy. [11]

*2.2.2. Tissue Doppler imaging*

**2.2. Echocardiography in LV diastolic dysfunction**

Patients with DHF were shown to have similar pathophysiological characteristics, compared with HF patients with a reduced EF including reduced exercise capacity and impaired quality of life. DHF will be present in heart failure with preserved ejection fraction. When it is difficult with diagnosing HF, it is important to use echocardiography. [7,8]

#### **2.1. The diagnosis of DHF**

The diagnosis of heart failure with preserved left ventricular (LV) ejection fraction (HFpEF) requires the following conditions to be satisfied: (1) signs or symptoms of heart failure; (2) normal or mildly abnormal systolic LV function; (3) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV enddiastolic volume index (LVEDVI) < 97 mL/m2 . Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler imaging (TDI) (E/E' >15) with an echocardiography. If TDI yields an E/E' ratio suggestive of diastolic LV dysfunction ( 8 < E/E' < 15 ), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echocardiographic measures of LV mass index or left atrial volume index, electrocar‐ diographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma BNP is more than 200 pg/mL, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations.

A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFpEF in patients with breathlessness and no signs of congestion. If a patient with breathlessness and no signs of fluid overload has a BNP of less than 100 pg/mL, any form of heart failure is virtually ruled out because of the high negative predictive value of the natriuretic peptides, and pulmonary disease becomes the most likely cause of breathlessness. [9, 10]

As far as diastolic dysfunction, in decompensated patients with advanced systolic heart failure (LVEF≦30%, New York Heart Association class III to IV symptoms), tissue Doppler-derived with E/E' ratio may not be as reliable in predicting intracardiac filling pressures, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac resynchronization therapy. [11]

#### **2.2. Echocardiography in LV diastolic dysfunction**

**2. The mechanism of DHF**

2 Hot Topics in Echocardiography

collagen volume fraction was equally elevated.

diastolic volume index (LVEDVI) < 97 mL/m2

additional non-invasive investigations.

**2.1. The diagnosis of DHF**

with diagnosing HF, it is important to use echocardiography. [7,8]

Heart failure is a clinical syndrome characterized by symptoms and signs of increased tissue water and decreased tissue perfusion. Definition of the mechanisms that cause this clinical syndrome requires measurement of both systolic and diastolic function. When heart failure is accompanied by a predominant or isolated abnormality in diastolic function, this clinical syndrome is called diastolic heart failure. The pathophysiology is attributed to LV diastolic dysfunction, in which LV diastolic chamber size is normal or reduced despite elevated filling pressures resulting in decreased cardiac output. DHF occurs when the ventricular chamber is unable to accept an adequate volume of blood during diastole, because of a decrease in ventricular relaxation and/or an increase in ventricular stiffness,[2] and increased circulating blood volume is present. Hypertension, ischemia, aging and diabetes mellitus are the major risk factor of a decrease in ventricular relaxation and/or an increase in ventricular stiffness. Endocardial biopsies from HF patients without coronary artery disease (CAD) showed structural and functional differences in cardiomyocytes from patients with diastolic HF compared to cardiomyocytes from patients with abnormal systolic ejection fraction.[6] Myocytes from patients with diastolic HF had increased diameter and higher myofibrillar density and developed greater passive force and had greater calcium sensitivity. Myocardial

Patients with DHF were shown to have similar pathophysiological characteristics, compared with HF patients with a reduced EF including reduced exercise capacity and impaired quality of life. DHF will be present in heart failure with preserved ejection fraction. When it is difficult

The diagnosis of heart failure with preserved left ventricular (LV) ejection fraction (HFpEF) requires the following conditions to be satisfied: (1) signs or symptoms of heart failure; (2) normal or mildly abnormal systolic LV function; (3) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-

can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler imaging (TDI) (E/E' >15) with an echocardiography. If TDI yields an E/E' ratio suggestive of diastolic LV dysfunction ( 8 < E/E' < 15 ), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echocardiographic measures of LV mass index or left atrial volume index, electrocar‐ diographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma BNP is more than 200 pg/mL, diagnostic evidence of diastolic LV dysfunction also requires

A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFpEF in patients with breathlessness and no signs of congestion. If a patient with breathlessness and no signs of fluid overload has a BNP of less

. Diagnostic evidence of diastolic LV dysfunction

#### *2.2.1. Doppler echocardiographic assessment of diastolic function and filling pressures*

Comprehensive Doppler echocardiography is invaluable in the evaluation of HF patients. It is established that the mitral E wave velocity reflects the LA-LV pressure gradient during early diastole and is therefore affected by preload and alterations in LV relaxation. Assessment of diastolic function begins with the transmitral flow velocity profile. Decreases in the ratio of early to late diastolic filling (E/A), increases in the deceleration time, increases in the isovolumic relaxation time, or increases in tissue Doppler imagings (E/E') indicate impaired relaxation. However, in the presence of impaired relaxation, increases in filling pressure progressively modify the transmitral gradient and mitral inflow pattern. A comprehensive Doppler assess‐ ment must be used to determine diastolic function from filling pressures and tissue Doppler imagings. [10] Patients studied at various times during their presentation will display a spectrum of filling patterns, including abnormal relaxation and psuedonormal or restrictive patterns. Such a spectrum has also been reported in patients with HF with a depressed EF and reflects the potent effect of filling pressures and blood pressure and their interaction with underlying diastolic dysfunction on the Doppler patterns. Thus, depending on their level of compensation and their filling pressures and whether they have exertional or rest symptoms, patients with HFpEF may display any of the filling patterns.[12]

#### *2.2.2. Tissue Doppler imaging*

Tissue Doppler imaging (TDI) is performed in the apical views to acquire mitral annular velocities with pulse wave. The sample volume should be positioned at 1 cm within the septal and lateral insertion sites of the mitral leaflets. It is recommended that spectral recordings be obtained at a sweep speed of 50 to 100 mm/s at end-expiration and that measurements should reflect the average of more than 3 consecutive cardiac cycles. Primary measurements include the systolic and early (e') and late (a') diastolic velocities. For the assessment of global LV diastolic function, it is recommended to acquire and measure tissue Doppler signals at least at the septal and lateral sides of the mitral annulus and their average. In patients with cardiac disease, e' can be used to correct for the effect of LV relaxation on mitral E velocity, and the E/ e' ratio can be applied for the prediction of LV filling pressures. The E/e' ratio is not accurate as an index of filling pressures in normal subjects or in patients with heavy annular calcifica‐ tion, mitral valve disease, and constrictive pericarditis.

Strain and strain rate can be derived from either tissue Doppler or speckle tracking 2-dimen‐ sional echocardiography. Using tissue Doppler, which is a form of pulsed Doppler, specific points within the myocardium can be identified. Tracking these Doppler points enables measurement of strain rate. Because Doppler is velocity or distance divided by time, the initial measurement is strain rate. Integrating the strain rate gives strain. The estimation of strain in the global left ventricular wall is called as global longitudinal strain (GLS).

A B

C D

A B

C D

C shows LV inflow. Panel D shows tissue Doppler imaging.

LV inflow. Panel D shows tissue Doppler imaging.

*2.2.3. Left ventricle in diastolic heart failure*

have variable degrees of LV enlargement.

**Figure 3.** Pseudonormalized pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel

Echocardiographic Evaluation of Left Ventricular Diastolic Function

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5

**Figure 4.** Restrictive pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows

Most patients with HFpEF have normal chamber dimensions, although a small subset may

**Figure 1.** Normal pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows LV inflow. Panel D shows tissue Doppler imaging.

**Figure 2.** Abnormal relaxation pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows LV inflow. Panel D shows tissue Doppler imaging.

**Figure 3.** Pseudonormalized pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows LV inflow. Panel D shows tissue Doppler imaging.

**Figure 4.** Restrictive pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows LV inflow. Panel D shows tissue Doppler imaging.

#### *2.2.3. Left ventricle in diastolic heart failure*

Strain and strain rate can be derived from either tissue Doppler or speckle tracking 2-dimen‐ sional echocardiography. Using tissue Doppler, which is a form of pulsed Doppler, specific points within the myocardium can be identified. Tracking these Doppler points enables measurement of strain rate. Because Doppler is velocity or distance divided by time, the initial measurement is strain rate. Integrating the strain rate gives strain. The estimation of strain in

C

D

**Figure 1.** Normal pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view. Panel C shows LV

**Figure 2.** Abnormal relaxation pattern in LV inflow: Panel A shows long axis view. Panel B shows 4 chamber view.

A B

C D

Panel C shows LV inflow. Panel D shows tissue Doppler imaging.

the global left ventricular wall is called as global longitudinal strain (GLS).

A

4 Hot Topics in Echocardiography

B

inflow. Panel D shows tissue Doppler imaging.

Most patients with HFpEF have normal chamber dimensions, although a small subset may have variable degrees of LV enlargement.

Although HF preserved EF has been thought to occur primarily patients with left ventricular hypertrophy (LVH), studies that have carefully quantified LV mass report that echocardio‐ graphic criteria for LVH are met in less than 50% of patients. [13-16]

and can be derived using inferior vena caval diameter and its change with respiration, as well

Echocardiographic Evaluation of Left Ventricular Diastolic Function

http://dx.doi.org/10.5772/55619

7

Pulse wave (PW) Doppler of pulmonary venous flow is performed in the apical 4-chamber view and aids in the assessment of LV diastolic function. A 2-mm to 3-mm sample volume is placed more than 0.5 cm into the pulmonary vein for optimal recording of the spectral waveforms. Measurements include peak S and D velocities, the S/D ratio, systolic filling fraction, and peak Ar velocity in late diastole. Another measurement is the time difference between Ar duration and mitral A-wave duration (Ar - A). With increased LV end-diastolic pressure, Ar velocity and duration increase, as well as the Ar - A duration. In patients with depressed EFs, reduced systolic filling fractions (less than 40%) are related to decreased LA compliance and increased mean LA pressure. Atrial fibrillation results in a blunted S wave

Regional wall motion abnormalities with preserved EF and right ventricular dilatation, either from ischemic disease or secondary to chronic pressure overload from chronic pulmonary venous hypertension, can also be present at echocardiography in patients with HFpEF. Additional negative findings at echocardiography include the absence of valvular disease, pericardial tamponade, pericardial constriction, the presence of congenital heart diseases such as atrial septal defect, other more extensive structural abnormalities are important enough to

HFpEF currently accounts for more than 50% of all heart failure patients. The updated strategies for the diagnosis and exclusion of HFpEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for

, Shota Fukuda, Hiroki Oe, Yukio Abe, Junichi Yoshikawa and

HFpEF. Echocardiography is useful for the diagnosis of HFpEF, noninvasively.

\*Address all correspondence to: wake123aha@yahoo.co.jp

Osaka City University Graduate School of Medicine, Japan

as the ratio of systolic to diastolic flow signals in the hepatic veins.

*2.2.7. Other echocardiographic findings in diastolic heart failure*

*2.2.6. Pulmonary venous flow*

and absence of Ar velocity.

cause the HF symptoms.

**3. Conclusions**

**Author details**

Minoru Yoshiyama

Ryotaro Wake\*

#### *2.2.4. Left atrium in diastolic heart failure*

Increases in the left atrial dimension or volume are commonly present in patients with HF preserved EF. [17-19] The left atrium modulates ventricular filling through its reservoir, conduit, and pump functions. During ventricular systole and isovolumic relaxation, when the atrioventricular (AV) valves are closed, atrial chambers work as distensible reservoirs accommodating blood flow from the venous circulation. The atrium is also a pumping chamber, which contributes to maintaining adequate LV end-diastolic volume by actively emptying at end-diastole. Finally, the atrium behaves as a conduit that starts with AV valve opening and terminates before atrial contraction and can be defined as LV stroke volume minus the sum of LA passive and active emptying volumes.

The measurement of left atrial (LA) volume is highly feasible and reliable in most echocardio‐ graphic studies, with the most accurate measurements obtained using the apical 4-chamber and 2-chamber views. This assessment is clinically important, because there is a significant relation between LA remodeling and echocardiographic indices of diastolic function. In the previous observational studies, patients without baseline histories of atrial fibrillation and significant valvular heart disease have shown that more than 34 mL/m2 LA volume index is an independent predictor of death, heart failure, atrial fibrillation, and ischemic stroke.

The dilated left atria may be seen in patients with bradycardia and 4-chamber enlargement, anemia and other high-output states, atrial flutter or fibrillation, and significant mitral valve disease, in the absence of diastolic dysfunction. Likewise, it is often present in elite athletes in the absence of cardiovascular disease. Therefore, it is important to consider LA volume measurements in conjunction with a patient's clinical status, other chambers' volumes, and Doppler parameters of LV relaxation.

#### *2.2.5. Pulmonary hypertension in diastolic heart failure*

Symptomatic patients with diastolic dysfunction usually have increased pulmonary artery (PA) pressures. [17,20] Therefore, in the absence of pulmonary disease, increased PA pressures may be used to infer the presence of elevated LV filling pressures. Indeed, a significant correlation was noted between PA systolic pressure and noninvasively derived LV filling pressures. The peak velocity of the tricuspid regurgitation (TR) jet by continuous-wave (CW) Doppler together with systolic right atrial (RA) pressure are used to derive PA systolic pressure. In patients with severe TR and low systolic right ventricular–RA pressure gradients, the accuracy of the PA systolic pressure calculation is dependent on the reliable estimation of systolic RA pressure. Likewise, the end-diastolic velocity of the pulmonary regurgitation (PR) jet can be applied to derive PA diastolic pressure. Both signals can be enhanced, if necessary, using agitated saline or intravenous contrast agents, with care to avoid overestimation caused by excessive noise in the signal. The estimation of RA pressure is needed for both calculations and can be derived using inferior vena caval diameter and its change with respiration, as well as the ratio of systolic to diastolic flow signals in the hepatic veins.

#### *2.2.6. Pulmonary venous flow*

Although HF preserved EF has been thought to occur primarily patients with left ventricular hypertrophy (LVH), studies that have carefully quantified LV mass report that echocardio‐

Increases in the left atrial dimension or volume are commonly present in patients with HF preserved EF. [17-19] The left atrium modulates ventricular filling through its reservoir, conduit, and pump functions. During ventricular systole and isovolumic relaxation, when the atrioventricular (AV) valves are closed, atrial chambers work as distensible reservoirs accommodating blood flow from the venous circulation. The atrium is also a pumping chamber, which contributes to maintaining adequate LV end-diastolic volume by actively emptying at end-diastole. Finally, the atrium behaves as a conduit that starts with AV valve opening and terminates before atrial contraction and can be defined as LV stroke volume

The measurement of left atrial (LA) volume is highly feasible and reliable in most echocardio‐ graphic studies, with the most accurate measurements obtained using the apical 4-chamber and 2-chamber views. This assessment is clinically important, because there is a significant relation between LA remodeling and echocardiographic indices of diastolic function. In the previous observational studies, patients without baseline histories of atrial fibrillation and significant valvular heart disease have shown that more than 34 mL/m2 LA volume index is an independent predictor of death, heart failure, atrial fibrillation, and ischemic stroke.

The dilated left atria may be seen in patients with bradycardia and 4-chamber enlargement, anemia and other high-output states, atrial flutter or fibrillation, and significant mitral valve disease, in the absence of diastolic dysfunction. Likewise, it is often present in elite athletes in the absence of cardiovascular disease. Therefore, it is important to consider LA volume measurements in conjunction with a patient's clinical status, other chambers' volumes, and

Symptomatic patients with diastolic dysfunction usually have increased pulmonary artery (PA) pressures. [17,20] Therefore, in the absence of pulmonary disease, increased PA pressures may be used to infer the presence of elevated LV filling pressures. Indeed, a significant correlation was noted between PA systolic pressure and noninvasively derived LV filling pressures. The peak velocity of the tricuspid regurgitation (TR) jet by continuous-wave (CW) Doppler together with systolic right atrial (RA) pressure are used to derive PA systolic pressure. In patients with severe TR and low systolic right ventricular–RA pressure gradients, the accuracy of the PA systolic pressure calculation is dependent on the reliable estimation of systolic RA pressure. Likewise, the end-diastolic velocity of the pulmonary regurgitation (PR) jet can be applied to derive PA diastolic pressure. Both signals can be enhanced, if necessary, using agitated saline or intravenous contrast agents, with care to avoid overestimation caused by excessive noise in the signal. The estimation of RA pressure is needed for both calculations

graphic criteria for LVH are met in less than 50% of patients. [13-16]

minus the sum of LA passive and active emptying volumes.

*2.2.4. Left atrium in diastolic heart failure*

6 Hot Topics in Echocardiography

Doppler parameters of LV relaxation.

*2.2.5. Pulmonary hypertension in diastolic heart failure*

Pulse wave (PW) Doppler of pulmonary venous flow is performed in the apical 4-chamber view and aids in the assessment of LV diastolic function. A 2-mm to 3-mm sample volume is placed more than 0.5 cm into the pulmonary vein for optimal recording of the spectral waveforms. Measurements include peak S and D velocities, the S/D ratio, systolic filling fraction, and peak Ar velocity in late diastole. Another measurement is the time difference between Ar duration and mitral A-wave duration (Ar - A). With increased LV end-diastolic pressure, Ar velocity and duration increase, as well as the Ar - A duration. In patients with depressed EFs, reduced systolic filling fractions (less than 40%) are related to decreased LA compliance and increased mean LA pressure. Atrial fibrillation results in a blunted S wave and absence of Ar velocity.

#### *2.2.7. Other echocardiographic findings in diastolic heart failure*

Regional wall motion abnormalities with preserved EF and right ventricular dilatation, either from ischemic disease or secondary to chronic pressure overload from chronic pulmonary venous hypertension, can also be present at echocardiography in patients with HFpEF. Additional negative findings at echocardiography include the absence of valvular disease, pericardial tamponade, pericardial constriction, the presence of congenital heart diseases such as atrial septal defect, other more extensive structural abnormalities are important enough to cause the HF symptoms.

#### **3. Conclusions**

HFpEF currently accounts for more than 50% of all heart failure patients. The updated strategies for the diagnosis and exclusion of HFpEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFpEF. Echocardiography is useful for the diagnosis of HFpEF, noninvasively.

#### **Author details**

Ryotaro Wake\* , Shota Fukuda, Hiroki Oe, Yukio Abe, Junichi Yoshikawa and Minoru Yoshiyama

\*Address all correspondence to: wake123aha@yahoo.co.jp

Osaka City University Graduate School of Medicine, Japan

#### **References**

[1] Braunwald, E. (1997). Shattuck lecture--cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. *N Engl J Med* 337 (19), 1360-1369

[14] Kawaguchi, M, et al. (2003). Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic

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9

[15] Kitzman, D. W, et al. (2002). Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure. *JAMA* 288 (17), 2144-2150

[16] Zile, M. R, et al. (2004). Diastolic heart failure--abnormalities in active relaxation and

[17] Lam, C. S, et al. (2009). Pulmonary hypertension in heart failure with preserved ejec‐ tion fraction: a community-based study. *J Am Coll Cardiol* 53 (13), 1119-1126

[18] Lam, C. S, et al. (2007). Cardiac structure and ventricular-vascular function in per‐ sons with heart failure and preserved ejection fraction from Olmsted County, Minne‐

[19] Melenovsky, V, et al. (2007). Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. *J Am Coll Car‐*

[20] Kjaergaard, J, et al. (2007). Prognostic importance of pulmonary hypertension in pa‐

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[14] Kawaguchi, M, et al. (2003). Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations. *Circulation* 107 (5), 714-720

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[1] Braunwald, E. (1997). Shattuck lecture--cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. *N Engl J Med* 337 (19), 1360-1369

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**Chapter 2**

**Right Chambers Quantification in Clinical Practice:**

**Resonance Imaging**

http://dx.doi.org/10.5772/55832

**1. Introduction**

Lucia Agoston-Coldea and Silvia Lupu

is triggered by left chamber impairment [7-9].

equipment and highly trained examiners.

Additional information is available at the end of the chapter

**Echocardiography Compared with Cardiac Magnetic**

The right ventricle (RV) has its own particular morphology and functions, which are different when compared to the left ventricle (LV). In clinical practice, the right heart chambers are often overlooked, as most physicians tend to focus more on LV and left atrium (LA) morphology and functions. However, cardiac pathology is often associated with right chambers impair‐ ment, which can occur as a primary pathophysiological response to elevated pressure in the pulmonary arterial circulation associated with primary pulmonary artery hypertension [1-2], in pulmonary diseases associated with pulmonary venous or arterial hypertension [3-4], pulmonary embolism [5], but also in congenital heart disease [6]. Most often, RV dysfunction

Right cardiac imaging is quite challenging, as there are few validated and reproducible parameters that can be employed for an accurate right atrium (RA) and RV morphology and function assessment. However, some imaging techniques are available for this purpose. Nowadays, cardiac magnetic resonance imaging (MRI) is the golden standard for right chambers evaluation [10], due to its unlimited imaging planes, higher image resolution, and the ability to calculate volumes using three-dimensional (3D) measurements. Regrettably, this type of evaluation is not available in many centres and rather expensive, requiring high quality

Although cardiac MRI is the preferred method [11], echocardiography remains a valuable alternative, as it is widely available, non-invasive, and less expensive and can be performed in all patients oblivious of associated pathology or the presence of metallic devices such as pacemakers, implanted cardioverter defibrillators, cochlear implants or drug infusion pumps.

> © 2013 Agoston-Coldea and Lupu; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.
