|Year : 2020 | Volume
| Issue : 1 | Page : 11-17
Role of Flow Propagation Velocity Across Mitral Valve in the Assessment of Diastolic Dysfunction and Prognostication in Acute Myocardial Infarction
Ravi Vishnu Prasad1, Kumar Vikram Singh1, K. K. Sethi2, Sukhvinder Singh2
1 Department of Cardiology, IGIMS, Patna, Bihar, India
2 Department of Cardiology, Non-Invasive Cardiac Laboratory, Delhi Heart and Lung Institute, Delhi, India
|Date of Submission||13-Jul-2019|
|Date of Acceptance||03-Nov-2019|
|Date of Web Publication||11-Apr-2020|
Dr. Ravi Vishnu Prasad
Department of Cardiology, IGIMS, Patna - 800 014, Bihar
Source of Support: None, Conflict of Interest: None
Background: The importance of left ventricular (LV) systolic dysfunction as a predictor of mortality and morbidity after acute myocardial infarction (MI) is well known. In MI, Doppler echocardiography can be used to determine the LV diastolic function, and a restrictive transmitral flow pattern has been related to the development of congestive heart failure and increased mortality. In patients with various etiologies of LV systolic dysfunction, restrictive filling has also proven to be an independent predictor of adverse outcome. Materials and Methods: 130 patients who presented with diagnosis of acute MI were included. Echocardiography was performed within 24 hours of arrival to the coronary care unit. Most widely used approach for measuring mitral-to-apical flow was used for velocity propagation. Based on the ratio E/Vp, patients divided into two groups with E/Vp <1.5 and E/Vp >1.5. Patients were followed up subsequently. Results: In the study population, the average age of patients was 59 ± 11.6 years. There were 105 male (80.77%) and 25 female patients (19.23%). On evaluation of risk factors, 69 patients (53.08%) were hypertensive, 71 patients (54.62%) were diabetic, 7 patients (5.38%) were smokers, and 43 patients (33.08%) had dyslipidemia. In patients with E/Vp <1.5, 31 patients (73.81%) had Grade I diastolic dysfunction (DD) and 10 patients (23.81%) had Grade II DD. One patient (2.38%) had Grade III DD. In patients with E/Vp >1.5, 20 patients (22.73%) had Grade I DD, 52 patients (59.09%) had Grade II DD and 16 patients (18.18%) had Grade III DD. Conclusion: In this echocardiographic study of 130 patients with MI E/Vp measured with color M mode is easily obtainable and this E/Vp is a strong predictor of heart failure and mortality. The ratio of peak E wave velocity to flow propagation velocity can be used with other diastolic function variables in predicting outcome. Furthermore, these Doppler variables may be used as simple tools to rapidly risk stratify patients with acute MI.
Keywords: Diastolic dysfunction, flow propagation velocity, mitral valve, myocardial infarction, two-dimensional echocardiography
|How to cite this article:|
Prasad RV, Singh KV, Sethi KK, Singh S. Role of Flow Propagation Velocity Across Mitral Valve in the Assessment of Diastolic Dysfunction and Prognostication in Acute Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:11-7
|How to cite this URL:|
Prasad RV, Singh KV, Sethi KK, Singh S. Role of Flow Propagation Velocity Across Mitral Valve in the Assessment of Diastolic Dysfunction and Prognostication in Acute Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Aug 13];4:11-7. Available from: http://www.jiaecho.org/text.asp?2020/4/1/11/282202
| Introduction|| |
Heart failure complicating acute myocardial infarction (MI) is associated with greatly increased morbidity and mortality. Left ventricular (LV) enlargement and systolic dysfunction are often present and are related to adverse outcomes in patients with MI. It has been shown that LV diastolic dysfunction (DD) is also present in 30%–40% of patients with clinical heart failure who have normal or nearly-normal systolic function. Systolic dysfunction and DD often coexist in patients with MI. Development of congestive heart failure (CHF) after acute MI has been shown to be significantly related to both LV systolic dysfunction and LV DD.
The importance of LV DD as a predictor of mortality and morbidity after MI is well known. In MI, Doppler echocardiography can be used to determine the LV diastolic function, and a restrictive transmitral flow pattern has been related to the development of CHF and increased mortality. In patients with various etiologies of LV systolic dysfunction, restrictive filling has also proven to be an independent predictor of adverse outcome.
The limitations of Doppler flow patterns are related to the difficulties in distinguishing between normal and pseudonormal filling pattern and to the influence of heart rate, age, and loading conditions on their measurements. The flow propagation velocity of early transmitral flow (Vp) determined from color M-mode recording is one of the more recently described parameters for the assessment of diastolic functions of the heart. It is a relatively load-independent parameter. It has been shown to be inversely related with the time constant of isovolumetric relaxation (tau), which is one of the standard invasive parameters of diastolic function. A combination of early filling velocity on mitral valve pulse wave Doppler and Vp is used to estimate LV end diastolic pressure (LVEDP). A strong correlation between the ratio of E to Vp (E/Vp) and LVEDP has been shown. E/Vp >1.5 was found highly predictive of elevated LVEDP., It may provide a simple tool to identify patients with pseudonormal filling pattern. The objective of this study is to assess the ability of E/Vp to predict heart failure in patients with MI and to assess the prognostic value of E/Vp on cardiac mortality. There have been some studies in the western world that has evaluated this method as a tool for evaluation of patient with DD and heart failure in MI, but data about this entity are limited in our country; hence, this study can emphasize the need to evaluate flow propagation velocity across mitral valve as a predictor of DD and prognostication in MI.
Aims and objectives
To determine the ability of ratio of peak E wave velocity to flow propagation velocity (E/Vp) measured with color M-mode Doppler echocardiography to predict heart failure and cardiac mortality in patients with MI.
| Materials and Methods|| |
One hundred and thirty patients who present to the coronary care unit with diagnosis of acute MI diagnosed by the WHO guidelines were included.
The study was conducted at Delhi Heart and Lung Institute, New Delhi and Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar.
This was a double-center, prospective, and observational study. Patients were followed up for 6 months after inclusion in the study and the total time duration for the study was 2 years.
- All patients admitted within 24 h of onset of their symptoms, with diagnosis of acute MI according to the WHO criteria of MI.
- Patients unwilling to give consent for participation in the study
- Severe LV hypertrophy
- Valvular heart disease
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy
- Restrictive cardiomyopathy
- Reinfarction/evidence of acute coronary syndrome in the past.
Patients were enrolled after satisfying the inclusion criteria. Written and informed consent was obtained from the patient.
Echocardiography was performed on VIVID-7 ultrasound machine from GE and Epiq, PHILIPS. The 3S sector transducer (probe) with a frequency of 1.5–3.6 MHz was used. Echocardiography was performed within 24 h of arrival to the coronary care unit.
Most widely used approach for measuring mitral-to-apical flow propagation is the slope method. The slope method has the least variability. Acquisition was performed in apical four-chamber view, using color flow imaging with a narrow color sector, and gain is adjusted to avoid noise. The M mode scan line was placed through the center of the LV inflow blood column from the mitral valve to the apex. Then, the color flow baseline was shifted to lower the Nyquist limit to ~ 60 cm/s so that the central highest velocity jet is blue. Flow propagation velocity (Vp) was measured as the slope of the first aliasing velocity during early filling, measured from the mitral valve plane to 4 cm distally into the LV cavity. In patients with low peak E wave velocity, with no color aliasing, baseline shift was adjusted to aliase at about 75% of the peak E wave velocity.
Based on visual impression of regional wall motion (WM), a WM obtained semi-quantitatively using a 17-segment model of the LV. LV volumes and ejection fraction were estimated using Simpson's modified biplane method. All patients had the assessment of DD by E/e' ratio and by pulmonary venous flow. This was important to avoid misinterpretation of DD solely by Vp or mitral inflow velocities. Assessment and grading of LV DD were done according to the European Society of Echocardiography guidelines, 2009.
Based on the ratio E/Vp, patients divided into two groups with E/Vp <1.5 and E/Vp >1.5,, which is suggestive of elevated LVED.
Patients were evaluated for reperfusion therapy in the form of thrombolysis, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass surgery (CABG) according to the ACC/AHA Guidelines for revascularization. Detailed records of the procedure during hospitalization were recorded.
Follow-up of patients
Patients were followed up either on their outpatient department (OPD) visit or readmission to hospital due to any cause with detailed clinical examination for signs and symptoms of heart failure. Patients were contacted on telephone at the end of 6 months after discharge for clinical status. All patients received standard treatment of MI which would include antiplatelet, beta-blocker, angiotensin-converting enzyme inhibitors/angiotensin receptor blocker, and antianginals as and when required.
Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± standard deviation and median. Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected, then nonparametric test was used.
Statistical tests were applied as follows:
- Quantitative variables were compared using unpaired t-test/Mann–Whitney test (when the data sets were not normally distributed) between the two groups
- Qualitative variables were compared using Chi-square test/Fisher's exact test
- Multivariate logistic regression was used to assess the significant risk factors of mortality and heart failure.
A P < 0.05 was considered statistically significant. The data were entered in MS Excel spreadsheet and analysis was done using Statistical Package for the Social Sciences version 2.0 (IBM, NY, USA).
| Results|| |
The baseline characteristics of study population are shown in [Table 1].
Of 130 patients, 42 patients had E/Vp ratio <1.5 constituting 32.31% of the study group while 88 patients had E/Vp ratio ≥ 1.5 constituting 67.69% of the study sample [Table 2].
|Table 2: Categorization of patient based on E wave velocity to flow propagation velocity|
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Based on diagnosis in the study sample, 30 patients (71.43%) had ST-segment elevation MI (STEMI) in the group with E/Vp <1.5 and 51 patients (57.95%) had STEMI in group with E/Vp >1.5 [Table 3].
|Table 3: Relation between diagnosis and E wave velocity to flow propagation velocity|
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In coronary angiography case with E/Vp <1.5, 19 patients (45.24%) had double-vessel disease (DVD) and single-vessel disease (SVD) each while four patients had triple-vessel disease (TVD). In patients with E/Vp >1.5, 32 patients (36.36%) had DVD, 24 patients (27.27%) had SVD, and 32 patients (36.36%) had TVD. In the study population, regional wall motion abnormality (RWMA) was present in 36 patients (85.71%) with E/Vp <1.5 and 73 patients (82.95%) had RWMA with E/Vp >1. Mitral regurgitation was present in 5 patients (11.90%) with E/Vp <1.5 and 29 patients (32.95%) had mitral regurgitation with E/Vp >1.5.
In case with E/Vp <1.5, 31 patients (73.81%) had Grade I DD and 10 patients (23.81%) had Grade II DD. One patient (2.38%) had Grade III DD. In patients with E/Vp >1.5, 20 patients (22.73%) had Grade I DD, 52 patients (59.09%) had Grade II DD and 16 patients (18.18%) had Grade III DD [Table 4].
|Table 4: Relation between diastolic dysfunction and E wave velocity to flow propagation velocity|
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Two patients (4.76%) died in E/Vp <1.5 and 18 patients (20.45%) died in E/Vp >1.5 [Table 5].
|Table 5: Relation between mortality and E wave velocity to flow propagation velocity|
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No heart failure cases were seen in patients E/Vp <1.5 and 12 patients (13.64) had heart failure in group with E/Vp >1.5 [Table 6] and [Table 7].
|Table 6: Relation between heart failure and E wave velocity to flow propagation velocity|
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|Table 7: Correlation among variable in groups with E wave velocity to flow propagation velocity <1.5 and >1.5|
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Twenty patients died during the study period [Table 8]. Various echocardiographic parameters were correlated with mortality in the study. Among patients who died, the mean ejection fraction of 38.25% was found to be statistically significant. Mean diastolic volume and end systolic volume was 74.9 ml/m2 and 44.25 ml/m2, respectively; these values did not correlate with mortality in this study. The mean mitral E velocity of 108 cm/s was found to be significantly relating with mortality in this study. It was seen that the mean mitral A velocity was 86.5 cm/s which was not statistically significant. These patients had E/A ratio of 1.48; this was correlating with mortality in the study. Mean deceleration time among patients who died was 174 ms; this did not predict mortality in the study. Mean mitral E/e in cases who died was 11.4 which was significantly relating with mortality in the study. Mean Vp was 44.85 cm/s which was found to be insignificant in predicting mortality. Mean pulmonary venous S/D ratio of 1.19 was found be significant in the study; however, the mean pulmonary A wave of 32.1 cm/s did not predict mortality in the study. Mean E/Vp among patients who died was 2.42; this was found to be independent predictor of mortality in the study.
There were 12 patients who developed heart failure during the study period. These cases had mean ejection fraction of 34.75%; this was found to be significant in the study. Mean end diastolic volume and end systolic volume were 97.5 ml/m2 and 56 m/m2, respectively, which were found to be significant in heart failure patients. Mean mitral E velocity was 91.42 cm/s and mitral A velocity was 72.67 cm/s; these values were found to be insignificant. Mean deceleration time in heart failure patients was 165 ms which predicted heart failure in the study. Patients with heart failure had mean E/e of 11.33; this was significant for heart failure cases. It was seen that the mean Vp among heart failure patient of 43.5 cm/s was predictor heart failure in the study. Mean pulmonary venous S/D ratio was found to be 1.2 and pulmonary venous A wave was 2.11 cm/s; these values were not found to be significant in this study. Mean E/Vp among heart failure patients was 2.11 which was found to be significant and independent marker for predicting heart failure in MI patient [Table 9].
| Discussion|| |
In our study, 130 patients of MI were admitted in Delhi Heart and Lung institute, Delhi, and IGIMS, Patna, Bihar. It is a double-center, observational, and prospective study. All patients were admitted to the coronary care unit. They were included in the study according to inclusion criteria and study protocol. Their parameters were recorded according to study protocol. Patient clinical history and examination was done. They were investigated for risk factors, and routine blood investigations were sent. After assessing the patients, they underwent coronary angiography and revascularization according to the ACC/AHA protocol.
In the study population, the average age of patients was 59 ± 11.6 years. There were 105 male (80.77%) and 25 female patients (19.23%). On evaluation of risk factors, 69 patients (53.08%) hypertensive, 71 patients (54.62%) diabetic, 7 patients (5.38%) smokers, and 43 patients (33.08%) had dyslipidemia.
Based on clinical examination, the patients were classified according to the Killip class and it was found that majority were in Killip Class I, i.e., 74 patients (56.92%). After evaluation of electrocardiogram, cardiac enzymes, and hs-troponin T report, 49 patients (37.69%) were diagnosed as non-STEMI and 81 patients (62.31%) with STEMI. All of them underwent coronary angiography in which DVD was found in 51 patients (39.23%), 43 patients (33.08%) had SVD, whereas 36 patients (27.69%) had TVD. Every patient underwent revascularization in the study according to protocol; culprit artery was identified and coronary angioplasty with stenting was done. PTCA with stenting to left anterior descending was done in maximum patients, i.e., 84 cases (64.62%), left circumflex in 17 patients (13.08%), right coronary artery in 35 patients (26.92%), and CABG was done in 4 patients (3.08%).
Two-dimensional echocardiography was done in the first 24 h of admission and parameters were recorded. Based on echocardiography, RWMA was seen in 109 patients (83.85%) and mitral regurgitation in 34 patients (26.15%). DD was seen in all patients. It was found that majority had Grade II DD, i.e., 62 patients (47.69%), 51 patients (39.23%) had Grade I DD, whereas 17 patients (13.08%) had Grade III DD.
Patient were divided into two groups with E/Vp <1.5 and E/Vp >1.5, which is suggestive of elevated LVEDP. They were followed up for 6 months after MI. All patients were seen either on their OPD visits or admission in hospital due to any cause. Detailed examination for signs and symptoms of heart failure was done during the follow-up. Every patient received standard treatment for MI which would include antiplatelet, beta-blockers, angiotensin-converting enzymes inhibitor/angiotensin receptor blocker, and antianginal as and when required.
In the study population, there were 12 patients (9.23%) who developed heart failure and during the study period. Eight out of 12 patients developed heart failure during their first admission and four patients were admitted for heart failure in their follow-up. Twenty (15.38%) patients died in first 6 months after MI. Sixteen out of 20 patients had in hospital mortality and four patients died during follow-up. Mortality was high in the study as this is a high volume tertiary care center where all complicated cases are referred for further management. Patients who died in this study were mainly in cardiogenic shock and had higher Killip class. A total of 124 patients were on regular follow up in hospital during first 6 months of study duration. Four patients did not follow up in hospital after first 4 months in this study. However, all alive patients' well-being and clinical status were confirmed on telephonic conversation.
Heart failure complicating myocardial infarction
In this study, there were 12 patients (9.23%) who developed heart failure during the study period. On evaluation, various parameters on echocardiography were found to be correlating with heart failure patients. These patients had higher end systolic and end diastolic volume, i.e., 55 ml/m2 and 97 ml/m2; these values were significant for predicting heart failure in the study and was correlating with the study done by Møller et al. in 2000.
In cases of MI, restrictive filling pattern has shown to be a predictor of heart failure due to elevated LVEDP. Elevated filling pressure is thought to increase left atrial pressure producing shortness of breath and signs of pulmonary congestion. This study showed that heart failure cases had higher E/A ratio and was found to be correlating well with study done by Quintana et al. It was also seen that the patient with deceleration time suggestive of restrictive filling was correlating with symptoms of heart failure during the study period and the results were found to be similar with study done by Quintana et al. and Giannuzzi et al., Patients with high E/e' suggestive of increase filling pressure had more incidence of heart failure and were found to be correlating with the study done by Ommen et al. Mean Vp among heart failure patient was 43.5 cm/s which was correlating well with symptoms and signs of heart failure in the study. It was similar to findings done by Møller et al. and Duval-Moulin et al. where pseudonormal and restrictive filling pattern predicted heart failure and mortality., On multivariate analysis, the mean E/Vp among heart failure cases was 2.11 and it was found to be an independent predictor of heart failure in this study. In this study, 42 patients had E/Vp <1.5 and there was no incidence of heart failure among them during the first 6 months. Among 76 patients with E/Vp >1.5, 12 cases of heart failure was seen during the study period and this findings was found to be significant. A study done by Møller et al. where E/Vp >1.5 which is suggestive of elevated LVEDP was found to be associated with higher incidence of heart failure and adverse outcome. Therefore, combination of various parameters on echocardiography such as end diastolic volume, end systolic volume, E/A ratio, deceleration time, E/E', Vp, and E/Vp >1.5 could be useful parameters to predict adverse outcome in patient with acute MI.
Twenty patients (15.38%) died during the first 6 months after myocardial revascularization. In this study, patient who died had mean ejection fraction of 38.25% and was correlating with mortality. It was found to be similar to studies done in the past for prediction of mortality. Several studies had shown that restrictive filling is a strong predictor of outcome in patient with acute MI.,,, Various parameters of DD and LV filling pattern are correlating with mortality in this study. Mean mitral E velocity among patients who died of 108 cm/s was found to be significant. Quintana et al. and Poulsen et al. showed that higher mitral E velocity was significantly associated with outcome; this finding was found in this study.,
In the absence of direct measurement of filling pressure, noninvasive measurement with use of E/Vp and E/e' has proved to be useful. In this study, it was demonstrated that E/e' correlated with incidence of adverse event after MI as was shown in the study done by Hillis et al., where higher E/e' value suggestive of high filling pressure was found to be predictive of mortality after MI. E/e' also allows risk stratification among patients with preserved as well as depressed LV systolic function. In the study done by Basnight et al., pulmonary venous flow velocity was helpful in identifying patient with DD and was found predicting adverse event. This study showed that pulmonary venous flow S/D ratio was predictive of adverse outcome in MI.
In the past, various studies have shown that restrictive pattern identified with deceleration time is powerful predictor of mortality after MI;, however, this study failed to demonstrate such correlation. Even decreased Vp, i.e. <45 cm/s suggestive of pseudonormal filling with normal deceleration time, has predicted mortality, but such correlation was not evident in this study., Under physiological condition, Vp has been demonstrated to be preload independent. Based on this finding, Vp has been used in combination with mitral E wave velocity to assess pseudonormal filling as demonstrated by Nijland et al. and the ratio of E/Vp allows for better estimation of filling pressure. In this study, the mean E/Vp among patients who died was 2.42 and found to be a predictor of mortality which was correlating with study done in the past., It was seen in the study done by Møller et al. that the presence of elevated LVEDP as assessed by E/Vp >1.5 is associated with worst prognosis. There were 42 patients (32.31%) with E/Vp <1.5 and 88 patients (67.69%) with E/Vp >1.5. In patients with E/Vp <1.5, 2 patients died and there were 18 deaths among with E/Vp >1.5 after MI in the first 6 months. Results in this study show that E/Vp >1.5 is an independent predictor of mortality after acute MI and correlated with study done by Møller et al.
This study shows E/Vp to be good predictor of prognosis and group with E/Vp <1.5 has favorable outcome. Therefore, combination of E/Vp, mitral E wave velocity, E/A ratio, E/E', and pulmonary S/D ratio could be used as simple tool to identify patient at high risk of adverse outcome after MI.
| Conclusion|| |
This echocardiographic study of inpatients with acute MI demonstrated that E/Vp measured with color M mode is easily obtainable and that E/Vp is a strong predictor of heart failure and mortality. The ratio of peak E wave velocity to flow propagation velocity can be used with other diastolic function variables in predicting outcome. Finally, these Doppler variables may be used as simple tools to rapidly risk stratify patient with acute MI.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]