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INTERESTING IMAGE
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 185-190

Effect of arrhythmias on tissue Doppler velocities


Department of Cardiology, Mittal Hospital and Research Centre, Ajmer, Rajasthan, India

Date of Web Publication10-Dec-2018

Correspondence Address:
Dr. Sita Ram Mittal
Xi/101, Brahmpuri, Ajmer - 305 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_16_18

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  Abstract 

Sa wave of tissue Doppler imaging correlates with ventricular systole (QRS-T of electrocardiogram). Ea wave correlates with ventricular filling in early diastole. Aa wave correlates with ventricular filling during atrial contraction and correlates with P wave of electrocardiogram. Therefore, a careful analysis of the relation between Ea and Aa waves gives a correct impression about the underlying cardiac arrhythmia. In sinus bradycardia, all waves are normal, but the distance between Ea and Aa wave is increased. In sinus tachycardia, Aa wave comes closer to Ea wave and may even fuse with Ea wave due to shortened diastole. Prematurely occurring Aa wave suggests atrial premature beat. The absence of Aa wave suggests atrial fibrillation. More than one Aa wave per cardiac cycle suggests atrial flutter. Premature Sa wave suggests ventricular premature beat. Increased distance between Aa wave and Sa wave suggests first-degree atrioventricular (AV) block. Progressive decrease of the distance between Ea and Aa waves till one Aa wave fuses with preceding Ea wave followed by a pause suggests Wenckebach phenomenon. In 2:1 AV block, one Aa wave is fused with Ea wave and the next Aa wave is followed by Sa and Ea waves. Sa and Ea waves occur regularly at a slow rate and Aa wave occurs regularly at a fast rate; thus, total dissociation between Ea and Aa waves suggests complete AV block. Usually, the person performing echocardiography is not aware of electrocardiography (ECG) findings. Clinicians may not be aware of the ECG findings when they are interpreting the tissue Doppler images. Further, arrhythmia recorded during tissue Doppler imaging need not necessarily be present in the 10 s ECG recorded routinely. Knowledge of the effect of arrhythmia on tissue Doppler findings helps in correct interpretation of the tissue Doppler findings.

Keywords: Arrhythmias, atrial fibrillation, atrial flutter, atrioventricular block, premature beats, tissue Doppler imaging


How to cite this article:
Mittal SR. Effect of arrhythmias on tissue Doppler velocities. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:185-90

How to cite this URL:
Mittal SR. Effect of arrhythmias on tissue Doppler velocities. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2019 May 23];2:185-90. Available from: http://www.jiaecho.org/text.asp?2018/2/3/185/247024




  Sinus Bradycardia Top


Sa wave and Ea wave are normal, but are at a slow rate [Figure 1]. Powerful atrial contraction may result in prominent Aa wave.
Figure 1: Tissue Doppler velocities from a case of sinus bradycardia. LTA: Lateral tricuspid annulus, RA: Right atrium, LA: Left atrium, RV: Right ventricle, LV: Left ventricle, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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  Sinus Tachycardia Top


Shortening of diastole results in diminished filling during early diastole. It is compensated by increased filling by forceful atrial contraction. Aa wave, therefore, becomes more prominent. Aa wave comes close to Ea wave due to shortened diastole [Figure 2]. With increasing heart rate, Ea and Aa waves fuse together [Figure 3].
Figure 2: Tissue Doppler velocities from a case of sinus tachycardia. Aa wave is prominent and close to Ea wave. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 3: Tissue Doppler velocities from a case of sinus tachycardia showing a fusion of Ea and Aa waves (IVCT, isovolumic contraction, S1 and S2, systolic waves). DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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  Supraventricular Ectopics Top


In atrial premature beats (premature P wave coming before QRS), Aa wave comes earlier (first and fourth beats in [Figure 4]). If the atrial ectopic is more premature and P wave of the ectopic fuses with the preceding T wave (second and fifth beats in [Figure 4]), Aa wave fuses with preceding Ea wave which becomes more prominent. Sinus beat (second beat in [Figure 5]) unmasks normal mid-diastolic reversal wave which is not visible in atrial premature beats. In some cases, Sa wave may be masked by opposite direction of Aa wave (third beat in [Figure 6]).
Figure 4: Effect of atrial premature beats on tissue Doppler velocities. Sinus beat (third beat) shows normal Ea and Aa waves (marked *). In atrial premature beats (first and fourth beats), Aa wave comes closer to Ea wave (marked **). In the second and fifth beats, Aa wave fuses with Ea wave which becomes more prominent (marked arrow). Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 5: Sinus beat (second beat) showing mid-diastolic reversal wave which is not visible in atrial premature beats (first, third, and fourth beats). MDR: Mid diastolic reversal, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 6: Absence of Sa wave (marked *) in the beat following atrial premature beat (third beat, marked as APB). DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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In junctional ectopic with retrograde atrial conduction (P' in the second beat of [Figure 7]), Sa is reduced (marked *) due to cancellation by Aa wave of the retrograde atrial activation.
Figure 7: Reduction in Sa velocity (marked *) due to retrograde activation of atria (marked P'). DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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  Atrial Fibrillation Top


Aa wave is absent [Figure 8]. The absence of Aa wave differentiates atrial fibrillation with a slow ventricular rate from the sinus bradycardia. The absence of Aa wave (marked * in [Figure 9]) also helps in diagnosing atrial fibrillation when no undulations are seen in the baseline (straight-line fibrillation) and the rhythm is regular due to the junctional rhythm. In atrial fibrillation with fast ventricular rate, irregularity of rhythm is difficult to appreciate. Sa wave closely follows Ea wave [Figure 10] with the result that Ea wave can be misinterpreted as fusion of Ea wave and Aa wave. The absence of Aa wave is (marked as * in [Figure 11]), however, clear in relatively long pause.
Figure 8: Atrial fibrillation with the absence of Aa wave (marked *). Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 9: Absence of Aa wave (marked *) in straight-line fibrillation with regular junctional rhythm. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 10: Sa wave immediately following the Ea wave in atrial fibrillation with a fast ventricular rate. Sa: Peak systole, Ea: Early filling

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Figure 11: Absence of Aa wave (marked *) in a longer pause in atrial fibrillation. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling

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  Atrial Flutter Top


Aa wave occurs with each atrial flutter wave. In atrial flutter with 2:1 atrioventricular (AV) conduction (second and third cycles in [Figure 12]), Aa wave fuses with Ea wave. In 3:1 AV conduction (first and fourth cycles in [Figure 12]), one Aa wave fuses with Ea wave and one separate Aa wave is seen. In 4:1 conduction [Figure 13], one Aa wave fuses with Ea wave and two separate Aa waves are seen (marked *).
Figure 12: Effect of atrial flutter (marked P) on tissue Doppler imaging. In 2:1 conduction (second and third cycles), Aa is fused with Ea wave. In 3:1 conduction (first and fourth cycles), a separate Aa wave is seen. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 13: Atrial flutter with changing atrioventricular conduction. In 4:1 atrioventricular conduction (fourth cycle), two separate Aa waves are seen (marked *). DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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  Atrioventricular Nodal Reentrant Tachycardia Top


Sa and Ea waves are normal. Atrial contraction occurs with ventricular contraction. Therefore, Aa wave is masked by Sa wave. No separate Aa wave is seen [Figure 14].
Figure 14: Tissue Doppler velocities in atrioventricular nodal reentrant tachycardia. No Aa wave is seen. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling

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  Ventricular Ectopics Top


Premature ventricular contraction produces a premature isovolumic contraction wave (IVC* in [Figure 15]). Aa wave of the previous sinus beat (Aa*) and Sa wave of the ventricular premature beat (Sa*) are less prominent due to mutual cancellation of velocities [Figure 15]. Ea wave and Aa wave following ventricular premature beat are normal. The distance between postectopic Ea wave and Aa wave is increased due to postectopic pause. In sinus tachycardia, clear differentiation of Ea and Aa waves is difficult due to superimposition of these waves due to shortened diastole. These waves separate during the postectopic pause (marked * in [Figure 16]). This allows correct evaluation of the velocities of these waves.
Figure 15: Effect of premature ventricular contraction (PVC) on tissue Doppler velocities. There is premature isovolumic contraction wave (IVC*). Aa* wave and Sa* wave following premature ventricular contraction are reduced. The distance between subsequent Ea and Aa waves is increased due to postectopic pause. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 16: Separation of Ea and Aa waves (marked *) during pause following premature ventricular contraction. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling, PVC: Premature ventricular contraction

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  Atrioventricular Block Top


In first-degree atrioventricular block

P-R interval is prolonged. P wave comes closer to T wave resulting in diminished distance between Ea and Aa waves. The distance between Aa wave and Sa wave is increased. If P-R interval is significantly prolonged, P wave may fuse with the preceding T wave. Ea and Aa waves fuse together [Figure 17].
Figure 17: Fusion of Ea and Aa wave due to first-degree atrioventricular block. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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In Wenckebach phenomenon

There is a progressive prolongation of P-R interval till a P wave is blocked. Progressive prolongation of P-R interval results in progressive shortening of T-P interval till one P wave fuses with the preceding T wave and is blocked. On tissue Doppler imaging, this phenomenon results in a progressive decrease in the distance between Ea and Aa waves till one Aa wave is fused with the preceding Ea wave (marked * in [Figure 18]). This is followed by a pause and normal Aa wave.
Figure 18: Effect of Wenckebach phenomenon on tissue Doppler velocities. There is a progressive decrease in the distance between Ea and Aa waves till one Aa wave fuses with the preceding Ea wave (marked *). This is followed by a pause and then a normal Aa wave. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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In 2:1 atrioventricular block

One P wave falls on preceding T wave and is blocked. The next P wave is conducted to the ventricles. Thus, only alternate P waves are conducted to the ventricles. On tissue Doppler imaging, one Aa wave fuses with the preceding Ea wave (marked * in [Figure 19]). It is followed by normal Aa wave and Sa wave. Tissue Doppler imaging alone may be confused with sinus bradycardia if attention is not paid to the accompanying electrocardiography (ECG) which shows alternate blocked P wave falling on T wave.
Figure 19: Effect of 2:1 atrioventricular block on tissue Doppler imaging. Alternate Aa wave is fused with Ea wave (marked *). DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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In complete atrioventricular block

There is a complete dissociation between P and QRS. P wave occurs regularly at a faster rate. QRS occurs regularly at a slow rate. There is no relation between P and QRS. On tissue Doppler imaging, Sa and Ea waves occur regularly at a slow rate. Aa wave occurs regularly at a faster rate [Figure 20]. Aa wave falling on the ST segment decreases the velocity of Sa wave. When Aa wave falls on the T wave, there is a fusion of Ea and Aa waves (marked * in [Figure 19]). P wave falling after the T wave produces independent Aa wave.
Figure 20: Effect of complete atrioventricular block on tissue Doppler imaging. Sa is regular at a slow rate. Aa is regular and at a faster rate. There is no relation between Sa and Aa. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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In paced rhythm

The relation between sinus P wave and paces QRS varies. Therefore, the relation between Ea and Aa waves also varies depending on the relation between P wave and preceding paces QRS [Figure 21]. When P wave falls within the paced QRS, Aa wave comes between isovolumic contraction wave and Sa wave [Figure 22].
Figure 21: Effect of ventricular pacing on tissue Doppler velocities. The relation between Ea and Aa wave varies depending on the relation between sinus P wave and the preceding paced QRS. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling

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Figure 22: Effect of ventricular pacing on tissue Doppler velocities. When sinus P wave falls within the paced QRS (PB), Aa wave comes after isovolumic contraction wave. DTI: Doppler tissue imaging, Sa: Peak systole, Ea: Early filling, Aa: Late filling, IVC: Iso volumic contraction

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  Conclusion Top


Usually, the person performing echocardiography is not aware of ECG findings. Clinicians may not be aware of the ECG findings when they are interpreting the tissue Doppler images. Further, arrhythmia recorded during tissue Doppler imaging need not necessarily be present in the 10 s ECG recorded routinely. Knowledge of the effect of arrhythmia on tissue Doppler findings helps in the correct interpretation of the tissue Doppler findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]



 

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  In this article
Abstract
Sinus Bradycardia
Sinus Tachycardia
Supraventricular...
Atrial Fibrillation
Atrial Flutter
Atrioventricular...
Ventricular Ectopics
Atrioventricular...
Conclusion
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