|Year : 2020 | Volume
| Issue : 2 | Page : 149-153
Atrioventricular Plane Displacement on Echocardiography in Patients with Left Ventricular Systolic Dysfunction
Sagar Divekar1, Vikrant Khese2, Madhusudan Asawa1, Deepak S Phalgune3, Chandrakant Chavan1
1 Department of Cardiology, Poona Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Cardiology, Bharati Hospital and Research Centre, Pune, Maharashtra, India
3 Department of Research, Poona Hospital and Research Centre, Pune, Maharashtra, India
|Date of Submission||17-Sep-2019|
|Date of Decision||03-Nov-2019|
|Date of Acceptance||05-Jan-2020|
|Date of Web Publication||19-Aug-2020|
Dr. Chandrakant Chavan
Department of Cardiology, Poona Hospital and Research Centre, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Atrioventricular plane displacement (AVPD) reflects global left ventricular function despite left ventricular asymmetry as it is determined in four different regions of left ventricle. The limitations of agreement between left ventricular ejection fraction (LVEF) and AVPD are not close enough for these two measurements to be interchangeable. There is reason to question whether AVPD provides the same information as LVEF. Aim: The aim of this study was to assess relations of AVPD with LVEF and clinical findings in patients left ventricular failure (LVF). Materials and Methods: One hundred patients aged ≥18 years with coronary artery disease admitted with LVF were included in this cross sectional study. Echocardiographic examination was performed. Left ventricular AVPD was evaluated by M mode, in the four and two chamber views. Primary aim was to compare AVPD with LVEF by echocardiography. Secondary outcome measures were comparison of AVPD with traditional risk factors, clinical features, and pro-B-type natriuretic peptide (BNP) levels. Comparison of qualitative and quantitative variables was done by using Chi-square test/Fisher's exact test and unpaired t-test. Pearson's correlation was used to study correlation. Results: Mean AVPD was significantly lower in patients with severe LVEF as compared to mild, and moderate LVEF. Correlation of AVPD with LVEF, pro BNP, septum, anterior, lateral and posterior wall hypokinesia was 0.895. 0.841, 0.898, 0.911, 0.893 and 0.907 respectively. Conclusions: Mean AVPD was significantly lower in patients with severe LVEF. Mean AVPD positively correlated with LVEF, pro BNP, septum, anterior, lateral and posterior wall hypokinesia.
Keywords: Atrioventricular plane displacement, echocardiography, left ventricular ejection fraction
|How to cite this article:|
Divekar S, Khese V, Asawa M, Phalgune DS, Chavan C. Atrioventricular Plane Displacement on Echocardiography in Patients with Left Ventricular Systolic Dysfunction. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:149-53
|How to cite this URL:|
Divekar S, Khese V, Asawa M, Phalgune DS, Chavan C. Atrioventricular Plane Displacement on Echocardiography in Patients with Left Ventricular Systolic Dysfunction. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2021 May 9];4:149-53. Available from: https://www.jiaecho.org/text.asp?2020/4/2/149/292627
| Introduction|| |
Left ventricular systolic function is usually expressed as ejection fraction and is most commonly measured by echocardiography. It can also be measured by radionuclide ventriculography or contrast cineangiography. Echocardiography is less complicated, less expensive, and less time consuming than either radionuclide ventriculography or ventricular angiography. Furthermore, ventricular angiography has the disadvantage that left ventricular ejection fraction (LVEF) may be overestimated because of stress to the patient, or underestimated because of the negative inotropic action of the contrast medium. Several echocardiographic techniques can be applied to evaluate left ventricular systolic function. The fractional shortening and Teichholz techniques are not reliable when left ventricular contraction is asymmetrical.,,
Cross sectional echocardiography tolerates asymmetry but requires good image quality for ade quate tracing of the endocardial borders, which is not always obtainable.,, Some investigators have reported that the limitations of agreement between LVEF determined by cross sectional echocardiography, and by radionuclide ventriculography or contrast cineangiography are quite disparate., It has been reported that cross sectional echocardiographic assessment of regional wall motion correlates well with hemodynamic status and is reliable and reproducible., However, it is time consuming and requires experienced investigators as well as good image quality.
The epicardial surface of the heart practically remains immobile during the cardiac cycle and normal left ventricular ejection cannot take place unless the atrioventricular plane moves which is the function of longitudinal myocardial fibers. During cardiac systole the atrioventricular plane moves towards the apex as a result of contraction of longitudinal fibers, and during diastole it moves away from the apex. The distance between the apex of the heart and the chest surface is constant during the cardiac cycle. The atrioventricular plane displacement (AVPD) is measured from the surface of the thorax, using transthoracic two dimensionally guided M mode echocardiography. AVPD reflects global left ventricular function despite left ventricular asymmetry, since it is determined in four different regions of the left ventricle: Septal, lateral, posterior, and anterior regions. It evaluates the total shortening along the left ventricular long axis in the respective regions. Taking into account the highly echogenicity of atrioventricular plane the examination is rapidly performed. However, the shortening of the left ventricular long axis, the shift of the atrioventricular plane, is a different aspect of function in comparison with the relation between stroke volume and end diastolic volume. Indeed, the limitations of agreement between LVEF and AVPD are not close enough for these two measurements to be interchangeable. There is a reason to question whether AVPD provides the same information as LVEF. Therefore, it is imperative to evaluate the value of AVPD before recommending it for general use. Hence, an attempt was made in the present study to assess relations of AVPD with clinical findings and LVEF in patients with left ventricular failure (LVF).
| Materials and Methods|| |
This prospective observational study was conducted between June 2016 and February 2018. After approval from the scientific advisory committee and institutional ethics committee, written informed consent was obtained from all the patients. Patients of coronary artery disease admitted with LVF, aged >18 years of either sex having heart rate between 60 bpm and 100 bpm were included. Patients with LVF other than coronary artery disease, patients with mobile apex and large pericardial effusion were excluded from this study.
The patients were assessed for cardiovascular risk factors that led to heart failure such as age, gender, hypertension, diabetes mellitus, dyslipidemia, smoking, family history of coronary artery disease, and body mass index. The Framingham criteria for the diagnosis of heart failure were taken into consideration with concurrent presence of either 2 major criteria or 1 major and 2 minor criteria. Paroxysmal nocturnal dyspnea, weight loss of 4.5 kg in 5 days in response to treatment, neck vein distension, rales, acute pulmonary edema, hepatojugular reflux, S3 gallop, central venous pressure >16 cm water, circulation time of 25 s, radiographic cardiomegaly were the major criteria whereas nocturnal cough, dyspnea on ordinary exertion, decrease in vital capacity by one-third the maximal value recorded, pleural effusion, heart rate ≥120/m, and bilateral ankle edema were the minor criteria. Criteria of coronary artery disease were based on 12 lead electrocardiogram, stress test, cardiac enzymes and coronary angiography.
A cross-sectional echocardiographic examination was performed with Philips IE 33 and transducer 5 MHz. An apical view was obtained during silent respiration or end expiratory apnoea with the patient in a left lateral recumbent position. Left ventricular AVPD was evaluated in two-dimensionally guided M mode, in the four and two chamber views. The regional displacement (mm) is the distance covered by the atrioventricular plane between the position most remote from the apex (corresponding to the onset of contraction) and the location closest to the apex (corresponding to the end of contraction including ejection shortening) that is, the full extent of the displacement. It was measured in the septal, lateral, posterior, and anterior regions, and calculated from an average of four measurements in patients with regular rhythm, and an average of eight measurements in patients with irregular rhythm was calculated [Figure 1] and [Figure 2].
|Figure 1:(A − B) + (C − D) + (E − F) + (G − H)/4= ------- Atrioventricular plane displacement value A - end diastole in 4 chamber view across septum B - end systole in 4 chamber view across septum C- end diastole in 4 chamber view across lateral wall D- end systole in 4 chamber view across lateral wall E - end diastole in 2-chamber view across septum F - end systole in 2 chamber view across septum G - end diastole in 2-chamber view across anterior wall H - end systole in 2 chamber view across anterior wall|
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The average AVPD in elderly controls is 14.5–15 mm, and a mean displacement >10.0 mm is usually considered normal as per study by Alam and Rosenhamer. The echocardiography was reviewed in order to determine whether an adequate endocardial tracing in the apical view could be performed for measurement of LVEF. Clinical echocardiographic examinations were performed according to routine indications. LVEF was calculated using Simpson's method. LVEF was classified as normal ≥55%, mild 45%–54%, moderate 30%–44%, and severe <30%. Patients were observed till discharge from the hospital or death.
Primary outcome measure was comparison of AVPD in systolic heart failure patients with LVEF by echocardiography. Secondary outcome measures were comparison of AVPD in left ventricular systolic heart failure patients with traditional risk factors, clinical features, Pro-B-type natriuretic peptide (BNP) level, angiographic findings, morbidity and mortality. On the basis of a previously published study, a sample size of 94 patients was calculated by a formula  with 80% power and 5% probability of Type I error to reject null hypothesis. We included 100 patients to validate the results.
Data collected were entered in Excel 2007 and analysis of data was done using Statistical Package for Social Sciences version 20, IBM, USA. The comparison of quantitative variables between the two groups was done using unpaired Student's t-test, comparison of variables between more than 2 groups was done by analysis of variance test. Comparison of qualitative variables was done by using Chi-square test or Fisher's exact test. Pearson's correlation was used to study correlation. The confidence limit for significance was fixed at 95% level with P < 0.05.
| Results|| |
Of 100 patients, 8%, 22%, 30%, 26% and 14% were between the age group of 35 and 45, 46 and 55, 56 and 65 and 66 and 75 and more than 75 years respectively [Table 1]. The mean age of the study population was 61.1 ± 12.1 years. Seventy one (71%) were males and 29% were female patients [Table 2]. Pulmonary rales, peripheral oedema, third heart sound and pulmonary congestion on X-ray was observed in 100%, 45%, 52% and 87% of study population respectively [Table 3]. 2.0%, 50%, 21%, and 27% patients had New York Heart Association Grades I, II, III and IV respectively [Table 4]. Hypertension, diabetes mellitus, dyslipidemia, history of smoking, history of previous coronary events, and history of coronary artery bypass graft was observed in 66%, 74%, 59%, 26%, 41%, and 22% of study population, respectively [Table 5].
In the present study, left anterior descending (LAD) artery (22%) was the most affected artery followed by triple vessel disease (TVD) (17%), right coronary artery (RCA) (9%) and left circumflex artery (LCX) (3%) [Table 6]. Mean AVPD was higher in single vessel coronary artery disease (LAD - 8.1 mm, LCX - 8.0 mm, RCA - 8.0 mm) compared to TVD (7.4 mm) though this difference was not statistically significant. Of 100 patients, 7% died, 39%, 42%, 6%, 4% and 2% and had hospital stay of 2, 3, 4, 5, and 6 days respectively. Mean AVPD was significantly lower in patients with severe LVEF as compared to mild and moderate LVEF [Table 7]. Mean AVPD was 8.2 mm and 6.9 mm in patients whose hospital stay was ≤5 days and >5 days respectively which was not statistically significant (P = 0.115). There was no statistically significant difference between mean AVPD with various coronary arteries involved as per the coronary angiography findings. Correlation of AVPD with LVEF, pro-BNP, septum, anterior, lateral, and posterior wall hypokinesia was 0.895. 0.841, 0.898, 0.911, 0.893, and 0.907, respectively [Table 8].
|Table 7: Comparison of left ventricular ejection fraction with mean atrioventricular plane displacement amongst study population|
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|Table 8: Correlation of atrioventricular plane displacement with left ventricular ejection fraction, pro B-type natriuretic peptide, septum, anterior, lateral and posterior wall atrioventricular plane displacement amongst study population|
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| Discussion|| |
Heart failure is major cause of high morbidity and mortality. Echocardiography is the most commonly used diagnostic test for heart failure. Determination of AVPD is entirely different modality for detection of left ventricular systolic function than traditional method of such as LVEF. Determination of left AVPD by echocardiography is an uncomplicated, rapid, reliable, and highly reproducible method for the assessment of LVF.,, It has been shown to correlate reasonably well with ejection fraction calculated by two-dimensional echocardiography, radionuclide ventriculography, as well as contrast cineangiography.,, It is particularly useful since it is readily measured even in patients with poor image quality., The magnitude of left AVPD is a strong prognostic marker in patients with heart failure.,
The present study compared AVPD with LVEF and other clinical as well as laboratory parameters. There was decrease in AVPD in patients with systolic LVF and it's value was useful in estimation of degree of heart failure. In the present study, there was significant positive correlation between AVPD and LVEF. Also there was significant positive correlation between AVPD and BNP a marker of heart failure.
The mean age of the present study was 61.1 ± 12.1 years. Alam and Rosenhamer  and Devasia et al. reported the mean age of 60 ± 9 years and 63.5 ± 14.7 years respectively. In the present study, males were 71% as compared to females 29%. Similar finding were reported by Banumathy et al., in which out of the 500 patients with acute heart failure, 310 (62.0%) were males and 190 (38.0%) were females.
In the present study, hypertension, diabetes mellitus, and dyslipidemia was observed in 74%, 48%, and 59% of study population respectively. Klapholz et al., reported hypertension in 78% and diabetes mellitus in 46% of cases. Dubourg et al., reported hypertension (61.2%) being most commonly associated risk factor followed by coronary artery disease (47.1%) and diabetes mellitus (24.6%). Devasia et al., observed that hypertension and diabetes mellitus was present in 33% and 16% patient's respectively. In the present study, 26% of study population were smokers. Banumathy et al., reported smoking in 22.2% patients.
In the present study, a significant positive correlation was observed between mean AVPD and LVEF (%), septum, anterior, lateral and posterior wall hypokinesia. In the present study, mean AVPD was 9.23 mm, 8.19 mm, and 7.19 mm in patients whose LVEF was between 45 and 54%, 30 <45%% and < 30% respectively (P = 0.0001). Alam and Höglund, reported mean AVPD 9.3 mm in patients whose mean LVEF was 46%. Many studies reported strong positive correlation of AVPD and LVEF (r = 0.87 and P < 0.001).,,,
In the present study, a significant positive correlation (r = 0.841) was observed between mean AVPD and BNP level (P < 0.0001). Rivera et al., reported a significant correlation between N-terminal pro-BNP concentration and AVPD (r = 0.34; P < 0.0001).
In the present study, LAD artery (22%) was the most affected artery followed by TVD (17%), RCA (9%) and LCX (3%). Mean AVPD was higher in single vessel coronary artery disease (LAD - 8.1 mm, LCX - 8.0 mm, RCA - 8.0 mm) compared to TVD (7.4 mm) though this difference was statistically not significant. Rydberg et al., reported AVPD 11.2 mm, 11.7 mm and12.1 mm in TVD, double vessel disease and single vessel disease respectively. They concluded that echocardiographically determined AVPD was related to prognosis in patients with chronic heart failure and in postmyocardial infarction patients.
In the present study, mean AVPD was lower in patients with >5 days hospital stay as compared to ≤5 days hospital stay though this difference was statistically not significant. There are some limitations in the present study. Annular displacement used for estimation of AVPD different in various sized heart while the contractility remain same. AVPD estimation can be affected by tethering and translation motion and it is unlikely that AVPD alone can provide a complete picture of cardiac function.
| Conclusions|| |
Mean AVPD was significantly lower in patients with severe LVEF. Mean AVPD positively correlated with LVEF, pro BNP, regional wall motion abnormality of LV.
We acknowledge Anirudh Allam for editing the article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]