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OBJECTIVE: To evaluate fetal lung development using pulmonary artery Doppler in pregnant women who had recovered from COVID-19. METHODS: The prospective case-control study included 41 pregnant women who had recovered from COVID-19 and 43 healthy pregnant women (control group). All the women in the study group had been diagnosed with COVID-19 and had completed a quarantine period. RESULTS: The demographic data of patients were similar in the groups (P > 0.05). Main pulmonary artery peak systolic velocity was higher and pulsatility indices were lower in pregnant women who recovered from COVID-19 compared to the controls (P

Background: Acceleration time (AT)/ejection time (ET) ratio is a marker of aortic valve stenosis (AS) severity and predicts outcome in moderate-severe AS. Methods: We explored the association of increased AT/ET ratio on prognosis in 1530 asymptomatic patients with presumably mild-moderate AS, normal ejection fraction, and without known diabetes or cardiovascular disease. Patients were part of the SEAS study (Simvastatin Ezetimibe Aortic Stenosis). Patients were grouped according to the optimal AT/ET ratio threshold to predict cardiovascular death and heart failure hospitalization. Low-gradient severe AS was identified as combined valve area ≤1.0 cm 2 and mean gradient Results: Higher AT/ET ratio was significantly associated with lower systolic blood pressure, lower left ventricular ejection fraction, lower stress-corrected midwall shortening, low flow, and with higher left ventricular mass and higher peak aortic jet velocity. AT/ET ratio ≥0.32 provided the optimal cutoff for predicting incident cardiovascular death and heart failure hospitalization in the total study sample. In patients with low-gradient severe AS, this threshold was >0.32. AT/ET ratio ≥0.32 had a 79% higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 1.79 [95% CI, 1.20–2.68]). In patients with low-gradient severe AS, AT/ET ratio >0.32 was associated with a 2-fold higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 2.15 [95% CI, 1.22–3.77]). Conclusions: In asymptomatic nonsevere AS and low-gradient severe AS, higher AT/ET ratio was associated with increased cardiovascular morbidity and mortality. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00092677.

Left ventricular systolic function is a good indicator of cardiac function and a powerful predictor of adverse cardiovascular (CV) outcomes. High ratio of pre-ejection period (PEP) to ejection time (ET) is associated with reduced left ventricular systolic function. Brachial PEP (bPEP) and brachial ET (bET) can be automatically calculated from an ankle-brachial index (ABI)-form device and bPEP/bET was recently reported to be a new and useful parameter of cardiac performance. However, there were no studies evaluating the utility of bPEP/bET for prediction of CV and overall mortality in patients with acute myocardial infarction (AMI). We included 139 cases of AMI admitted to our cardiac care unit consecutively. ABI, bPEP, and bET were obtained from the ABI-form device within the 24 hours of admission. There were 87 overall and 22 CV mortality and the median follow-up to mortality event was 98 months. After multivariable analysis, high bPEP/bET was not only associated with increased long-term CV mortality (hazard ratio (HR) = 1.046; 95% confidence interval (CI): 1.005–1.088; P = 0.029), but also associated with long-term overall mortality (HR = 1.023; 95% CI: 1.001–1.045; P = 0.042). In addition, age was also a significant predictor for CV and overall mortality after the multivariable analysis. In conclusion, bPEP/bET was shown to be a significant predictor for CV and overall mortality in AMI patients after multivariable analysis. Therefore, by means of this novel parameter, we could easily find out the high-risk AMI patients with increased CV and overall mortality.

OBJECTIVES: Fetal cardiac function can be evaluated using a variety of parameters. Among these, cardiac cycle time-related parameters, such as filling time fraction (FTF) and ejection time fraction (ETF), are promising but rarely studied. We aimed to report the feasibility and reproducibility of fetal FTF and ETF measurements using pulsed-wave Doppler, to provide reference ranges for fetal FTF and ETF, after evaluating their relationship with heart rate (HR), gestational age (GA) and estimated fetal weight (EFW), and to evaluate their potential clinical utility in selected fetal conditions. METHODS: This study included a low-risk prospective cohort of singleton pregnancies and a high-risk population of fetuses with severe twin-twin transfusion syndrome (TTTS), aortic stenosis (AoS) or aortic coarctation (CoA), from 18 to 41 weeks' gestation. Left ventricular (LV) and right ventricular inflow and outflow pulsed-wave Doppler signals were analyzed, using valve clicks as landmarks. FTF was calculated as: (filling time/cycle time) × 100. ETF was calculated as: (ejection time/cycle time) × 100. Intraclass correlation coefficients (ICC) were used to evaluate the intra- and interobserver reproducibility of FTF and ETF measurements in low-risk fetuses. The relationships of FTF and ETF with HR, GA and EFW were evaluated using multivariate regression analysis. Reference ranges for FTF and ETF were then constructed using the low-risk population. Z-scores of FTF and ETF in the high-risk fetuses were calculated and analyzed. RESULTS: In total, 602 low-risk singleton pregnancies and 54 high-risk fetuses (nine pairs of monochorionic twins with severe TTTS, 16 fetuses with AoS and 20 fetuses with CoA) were included. Adequate Doppler traces for FTF and ETF could be obtained in 95% of low-risk cases. Intraobserver reproducibility was good to excellent (ICC, 0.831-0.905) and interobserver reproducibility was good (ICC, 0.801-0.837) for measurements of all timing parameters analyzed. Multivariate analysis of FTF and ETF in relation to HR, GA and EFW in low-risk fetuses identified HR as the only variable predictive of FTF, while ETF was dependent on both HR and GA. FTF increased with decreasing HR in low-risk fetuses, while ETF showed the opposite behavior, decreasing with decreasing HR. Most recipient twins with severe TTTS showed reduced FTF and preserved ETF. AoS was associated with decreased FTF and increased ETF in the LV, with seemingly different patterns associated with univentricular vs biventricular postnatal outcome. The majority of fetuses with CoA had FTF and ETF within the normal range in both ventricles. CONCLUSIONS: Measurement of FTF and ETF using pulsed-wave Doppler is feasible and reproducible in the fetus. The presented reference ranges account for associations of FTF with HR and of ETF with HR and GA. These time fractions are potentially useful for clinical monitoring of cardiac function in severe TTTS, AoS and other fetal conditions overloading the heart. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

OBJECTIVES Aortic acceleration time (AAT) and the ratio of AAT to ejection time (AAT/ET) are relatively new echocardiographic measures of the severity of aortic stenosis (AS). This study investigated the utility of transesophageal echocardiography (TEE) measurements of AAT and AAT/ET to predict the severity of AS under intraoperative conditions. DESIGN Retrospective diagnostic accuracy study. SETTING St. Vincent's Hospital, Melbourne, Australia, from July 2007 to February 2017. PARTICIPANTS The study comprised 199 patients who underwent aortic valve replacement (AVR) and whose aortic valves were evaluated with spectral Doppler analysis in both preoperative transthoracic echocardiography (TTE) and intraoperative TEE studies fewer than three months apart. Exclusion criteria included AVR for only aortic regurgitation, AVR of prosthetic aortic valves, and known left ventricular outflow tract obstruction. MEASUREMENTS AND MAIN RESULTS Standard echocardiography assessment of AS and the AAT and AAT/ET measurements was performed using preoperative TTE and intraoperative TEE. The intraoperative AAT and AAT/ET were increased significantly in patients with both high- and low-gradient severe AS compared with patients without severe AS (p < 0.01). Comparing preoperative TTE and intraoperative TEE measurements showed that the AAT was significantly prolonged during general anesthesia (mean difference 9.67 msec [95% confidence interval -13.54 to -5.81]), whereas the AAT/ET was preserved (mean difference -0.0018 [95% confidence interval -0.013 to 0.0091]). An intraoperative TEE cutoff of 109 msec for AAT and 0.35 for AAT/ET had a 74% and 67% sensitivity and 72% and 78% specificity, respectively, to differentiate severe from non-severe AS. CONCLUSIONS The AAT and AAT/ET may be useful adjuncts for the intraoperative measurement of AS. The agreement between intraoperative TEE and preoperative TTE was better with AAT/ET compared with AAT alone.

Objective Transient tachypnea of the newborn (TTN) is the leading cause of neonatal morbidity in preterm deliveries and has been reported in term small-for-gestational-age (SGA) fetuses; therefore, determination of fetal lung maturity before delivery is extremely important. Our present study aimed to evaluate the ratio of fetal pulmonary artery acceleration time to ejection time (At/Et) in uncomplicated term SGA fetuses and whether this ratio changes with TTN. Study design One hundred seventy-five pregnant women with uncomplicated pregnancies who delivered after 37 gestational weeks were included in this cross-sectional study. Participants were divided by birth weight percentiles into SGA (n = 86) and healthy control groups (n = 89). All participants underwent ultrasound examination to determine fetal pulmonary artery At/Et. After delivery, the neonates were grouped according to diagnosis of TTN (i.e., TTN-positive SGA group [n = 14], TTN-negative SGA group [n = 72], and TTN-negative control group [n = 86]), and the fetal pulmonary artery At/Et was compared between the two. Results Maternal demographic characterizes were similar between groups. At/Et was 0.309 ± 0.181 in the SGA group and 0.348 ± 0.213 in the control group and was significantly lower in the SGA group. At/Et was 0.290 ± 0.007 in the TTN-positive SGA group, 0.313 ± 0.017 in the TTN-negative SGA group, and 0.351 ± 0.186 in the TTN-negative control group, a significant difference. Additionally fetal pulmonary artery At/Et was found to be inverse correlated with TTN. (-0,464 P = 0.000). The cut-off value of 0.298 provided optimal specificity of 93.0 % and sensitivity of 81.0 % for subsequent diagnosis of TTN in term SGA newborns in the neonatal period. Conclusion The risk for TTN increases in uncomplicated term SGA fetuses. The fetal pulmonary artery At/Et appears to be a noninvasive useful method by which to predict TTN in these fetuses.

AIMS Worsening heart failure (HF) is associated with shorter left ventricular systolic ejection time (SET), but there are limited data describing the relationship between SET and clinical outcomes. Thus, the objective was to describe the association between SET and clinical outcomes in an ambulatory HF population irrespective of ejection fraction (EF). METHODS AND RESULTS We identified ambulatory patients with HF with reduced EF (HFrEF) and HF with preserved EF (HFpEF) who had an outpatient transthoracic echocardiogram performed between August 2008 and July 2010 at a tertiary referral centre. Multivariable logistic regression was used to evaluate the association between SET and 1-year outcomes. A total of 545 HF patients (171 HFrEF, 374 HFpEF) met eligibility criteria. Compared with HFpEF, HFrEF patients were younger [median age 60 years (25th-75th percentiles 50-69) vs. 64 years (25th-75th percentiles 53-74], with fewer females (30% vs. 56%) and a similar percentage of African Americans (36% vs. 35%). Median (25th-75th percentiles) EF with HFrEF was 30% (25-35%) and with HFpEF was 54% (48-58%). Median SET was shorter (280 ms vs. 315 ms, P

An increased acceleration time to ejection time (AT/ET) ratio is associated with increased mortality in patients with aortic stenosis (AS).To identify the factors associated with an increased AT/ET ratio.The relationships between the AT/ET ratio and clinical and Doppler echocardiographic variables of interest in the setting of AS were analysed retrospectively in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (LVEF). The computed tomography aortic valve calcium (CT-AVC) score was studied in a subgroup of 342 patients.In the univariate analysis, the AT/ET ratio was found to correlate with peak aortic jet velocity (r=0.57; P0.0001), mean pressure gradient (r=0.60; P0.0001), aortic valve area (r=-0.50; P0.0001) and CT-AVC score (r=0.24; P0.0001). The AT/ET ratio had good accuracy in predicting a peak aortic jet velocity≥4 m/s, a mean pressure gradient≥40mmHg and an aortic valve area≤1.0cmThe AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond the haemodynamic and anatomical severity of AS influence the AT/ET ratio, including LV geometry, function and systolic blood pressure. These findings should be considered when assessing the AT/ET ratio in patients with AS and preserved LVEF.

PubMed ID: 29212398, Objective: We aimed with this study to evaluate the role of pulmonary artery acceleration time to ejection time ratio (PATET) in the prediction of respiratory distress syndrome (RDS) in preterm neonates. Materials and methods: In this prospective cohort study, 105 singleton pregnant women with no congenital abnormalities and pregnancy complications who delivered before 37 weeks of gestational age were included. All the patients underwent ultrasound examination to obtain fetal pulmonary artery Doppler. 15 patients were excluded from the study as they did not give birth within 3 days subsequent to ultrasound examination, or inadequate Doppler measurements. After delivery the neonates were grouped according to diagnosis of RDS as RDS + and RDS-. Results: One hundred five women met the inclusion criteria. Regarding the Doppler findings; only the PATET ratio was significantly different between the groups (0.2965 ± 0.042 versus 0.386 ± 0.068 p

Objective: To determine the prognostic accuracy of the fetal pulmonary artery acceleration time/ejection time (PATET) for the prediction of neonatal respiratory complications (NRCs) in pregnancies ...

PurposeThe pre-ejection period-derived myocardial performance index measured from tissue Doppler echocardiography (PEPa-derived MPI) was reported to be associated with left ventricular systolic and diastolic function in atrial fibrillation (AF). However, its relationship with cardiovascular outcomes in AF has never been evaluated. This study sought to examine the ability of PEPa-derived MPI in predicting adverse cardiovascular events in AF patients.MethodsIn 196 persistent AF patients, we performed comprehensive echocardiography with measurement of PEPa-derived MPI using index beat method. The index beat was defined as the beat following the nearly equal preceding (RR1) and pre-preceding (RR2) intervals. The cycle length of index beat and RR1 and RR2 must be >500ms and the difference between RR1 and RR2 must be

ObjectivesWe sought to evaluate whether ejection dynamics, particularly acceleration time (AT) and the ratio of AT to ejection time (ET), can differentiate prosthetic aortic valve (PAV) stenosis from controls and prosthesis–patient mismatch (PPM).BackgroundDiagnosing PAV stenosis, especially in mechanical valves, may be challenging and has significant clinical implications.MethodsDoppler echocardiography was quantitated in 88 patients with PAV (44 mechanical and 44 bioprosthetic; age 63 ± 16 years; valve size range 18 to 25 mm) of whom 22 patients had documented PAV stenosis, 22 had PPM, and 44 served as controls. Quantitative Doppler parameters included ejection dynamics (AT, ET, and AT/ET) and conventional PAV parameters.ResultsPatients with PAV stenosis had significantly lower effective orifice area (EOA) values and higher gradients compared with controls and PPM. Flow ejection parameters (AT and AT/ET) were significantly longer in the stenotic valves compared with PPM and controls (respective values for AT: 120 ± 24 ms, 89 ± 16 ms, and 71 ± 15 ms; for AT/ET: 0.4, 0.32, and 0.3, p ≤ 0.001). Patients with PPM had gradients and ejection dynamics that were intermediate between normal and stenotic valves. Receiver-operator characteristic (ROC) curve analysis showed that AT and AT/ET discriminated PAV stenosis from PPM and controls (area under ROC curve = 0.92 and 0.88, respectively). Combining AT with the conventional Doppler velocity index gave the highest area under the curve of 0.98 but was not statistically different from that of AT alone (p = 0.12). A cutoff of AT = 100 ms had a sensitivity and specificity of 86% for identifying PAV stenosis; for an AT/ET = 0.37, the sensitivity and specificity were 96% and 82%, respectively. Analysis by valve type (mechanical and biological) revealed similar results; however, biological valves had slightly higher areas under the curve for all systolic time intervals.ConclusionsEjection dynamics through PAV, particularly AT and AT/ET, are reliable angle-independent parameters that can help evaluate valve function and identify PAV stenosis.

Objective To assess the learning curve for measurement of the fetal modified myocardial performance index (MPI). Methods Three trainees with the theoretical knowledge of but without prior experience in performing MPI measurement were selected. Each trainee and one experienced examiner measured MPI in a cohort of 90 consecutive fetuses. The average difference between the three trainees and the expert in the MPI measurements was calculated; a difference below 10% was considered to indicate an accurate measurement. Individual and averaged learning curves were delineated using cumulative sum analysis (CUSUM). Results The gestational age at evaluation ranged from 20 + 4 to 41 + 4 (mean, 33 + 3) weeks. The CUSUM plots demonstrated that, on average, competence in performing fetal MPI measurement was achieved by 65 cases. The average number of attempts to achieve competence were 42, 77 and 83 for the ejection time, isovolumetric contraction time and isovolumetric relaxation time, respectively. Conclusions Evaluation of fetal MPI by an inexperienced trainee requires on average 65 measurements to achieve competence. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

SummaryPurposeTo determine the acute change in cardiac performance after intravenous immunoglobulin infusion (IVIG) in patients with acute Kawasaki disease (KD).Materials and methodsSubjects were 33 patients with KD who were treated with IVIG 2g/kg and recovered without coronary artery lesion and 27 controls. Subjects underwent combined two-dimensional, Doppler, and tissue Doppler echocardiographic (TDI) studies. In KD, these echocardiographic studies were performed before IVIG, 48h after IVIG, and in convalescence. Echocardiographic variables were compared between KD and controls as well as among 3 time points in KD.ResultsBefore IVIG, KD showed significantly higher peak aortic velocity and shorter aortic ejection time as results of tachycardia and significantly lower E′ (p

WOS: 000251636700015, PubMed ID: 18029333, Myocardial performance index (MPI) has been regarded as an important parameter in the evaluation of ventricular systolic function in congestive heart failure. This study was designed to investigate the relationship between the ratio of isovolumic contraction time/left ventricular ejection time (IVCT/LVET), MPI, and LV systolic function. A total of 43 patients (patient group) with LV ejection fractions (LVEFs) = 55%. LVEF was measured in all cases by 2-dimensional echocardiography via the modified Simpson method. Isovolumic relaxation time (IVRT), IVCT, LVET, ratio of IVCT/LVET, and MPI ([IVRT+IVCT]/LVET) were measured via Doppler echocardiography. The mean value for lVCT was found to be significantly higher (P

Background Myocardial performance index (MPI) has been used to assess global ventricular function in different types of cardiac disease. Thyroid hormones influence cardiac performance directly and indirectly by changes in peripheral circulation. The aim of this study was to evaluate the possible effect of central hypothyroidism (CH) on MPI. Methods The study included 28 control subjects and 7 patients with CH without cardiac disease. MPI was defined as the sum of isovolumetric contraction time (ICT) and isovolumetric relaxation time divided by ejection time. Patients were submitted to hormonal therapy with thyroxin and the study was repeated after 35 to 42 days. Results MPI was significantly higher in patients with CH (0.54 ± 0.08) than in control subjects (0.40 ± 0.05) ( P = .002). The increase in MPI was caused by the prolongation of ICT without a significant variation of isovolumetric relaxation time and ejection time. After hormonal therapy there was a significant reduction of MPI (0.54 ± 0.08 vs 0.42 ± 0.07; P = .028) and ICT. Conclusion MPI was increased in patients with untreated CH. The increase was related to prolongation of ICT and reverted by hormonal therapy.

Objective: To determine whether the acceleration/ejection time ratio of the fetal main pulmonary artery Doppler waveform (PATET) can accurately predict the results of fetal lung maturity testing in amniotic fluid. Methods: We prospectively studied pregnant women attending our ultrasound unit for clinically indicated fetal lung maturity testing. An ultrasound examination that included measurement of the PATET was performed before the results of the amniocentesis were reported. The results of the PATET and the surfactant/albumin ratio were compared, and a receiver operating characteristic curve was used to determine the PATET cutoff with the optimal sensitivity and specificity for predicting surfactant/albumin ratio results. p < 0.05 was considered statistically significant. Results: Forty-three patients were included in this study. The receiver operating characteristic curve demonstrated that a PATET cutoff of 0.3149 provided a specificity of 93% (95% CI 77-98%), a sensitivity of 73% (95% CI 48-89%), a negative predictive value of 87% (95% CI 70-95%), and a positive predictive value of 85% (95% CI 58-96%) for predicting immature surfactant/albumin ratio results. Conclusion: The PATET may provide a noninvasive means of determining fetal lung maturity with acceptable levels of sensitivity, specificity, and predictive values.

Arterial stiffness is correlated with left ventricular (LV) diastolic function as well as susceptibility to LV systolic function. Therefore, if LV systolic function is not known, the relationship between arterial stiffness and LV diastolic function is difficult to determine. A total of 260 patients were included in the study. The brachial-ankle pulse wave velocity (baPWV) and the ratio of right brachial pre-ejection period to ejection time (rbPEP/rbET) were measured using an ABI-form device. Patients were classified into four groups. Groups 1, 2, 3 and 4 were patients with rbPEP/rbET and baPWV below the median, rbPEP/rbET above but baPWV below the median, rbPET/rbET below but baPWV above the median, and rbPET/rbET and baPWV above the median, respectively. The LV ejection fractions in groups 1 and 3 were higher than those in groups 2 and 4 (P

Impaired left ventricular systolic function is an important cause of mortality in hemodialysis patients. An increase in the ratio of pre-ejection period (PEP) to ejection time (ET) is associated with a decrease in left ventricular systolic function. Brachial PEP (bPEP) and brachial ET (bET) can be automatically determined from an ankle-brachial index (ABI)-form device. The aim of this study was to investigate whether bPEP/bET was a useful predictor for overall and cardiovascular mortality in hemodialysis patients. We enrolled 212 hemodialysis patients in one regional hospital. The bPEP and bET were measured using an ABI-form device. The mean follow-up period was 28.3+/-5.7 months. The relative mortality risk was analyzed by Cox-regression methods. Twenty-two deaths were recorded in 212 patients (10.4%). In a multivariate analysis, the bPEP/bET (hazard ratio [HR], 1.055; P=0.047) and serum creatinine level (P=0.029) were positively and negatively associated with overall mortality, respectively. In addition, increased bPEP/bET (HR, 1.080; P=0.017), increased fasting glucose (P=0.046) and decreased serum creatinine level (P=0.004) were independent predictors for cardiovascular mortality. Our findings show that bPEP/bET, a surrogate of left ventricular systolic function, is a useful predictor for overall and cardiovascular mortality in hemodialysis patients. Screening hemodialysis patients by means of bPEP/bET may help to identify a high-risk group for increased mortality.

This study aimed to describe the electromyographic (EMG) activity patterns of the genioglossus (GG) and suprahyoid (SHy) muscles during swallowing. The effects of changes in food texture/consistency and head posture on transport of the swallowed bolus were also investigated. Participants were 10 normal adults. Test foods consisted of a liquid, a syrup, or 4 ml of paste made from 0.5% or 1.0% agar. Each food was swallowed with the head in one of three positions, and EMGs and videofluorographic (VF) images were recorded. Mean values of onset, peak, and offset times, peak amplitude, area, and duration of the EMG burst were measured. The total swallowing time, oral ejection time, pharyngeal transit time, clearance time, fauces transit time, and upper esophageal sphincter (UES) transit time were measured. The GG muscle burst patterns showed two peaks (GG1 and GG2) during each swallowing. The offset time and duration of the GG1 burst and the onset, peak, and offset times and duration of both the GG2 and SHy bursts were significantly affected by food texture. There were no significant differences in bolus transit time among the different experimental conditions. Regression analyses demonstrated significant linear relationships between the tongue tip touching the palate and the peak of the GG1 burst, between passage of the bolus tail at the fauces and offset of the GG1 burst, between passage of the bolus tail at the UES and peak of the GG2 burst, and between passage of the bolus tail at the UES and offset of the SHy burst. These results demonstrate that the duration, but not the amplitude, of tongue and suprahyoid muscle activity were increased with increasing hardness of food during swallowing and that the bolus transit time can be fixed within a certain range of physical food properties.

Molecular motors housed in myosins of the thick filament react with thin-filament actins and promote force and shortening in the sarcomeres. However, other actions of these motors sustain sarcomeric activation by cooperative feedback mechanisms in which the actin-myosin interaction promotes thin-filament activation. Mechanical feedback also affects the actin-myosin interaction. We discuss current concepts of how these relatively under-appreciated actions of molecular motors are responsible for modulation of the ejection time and isovolumic relaxation in the beating heart.

Background The Tei index is a useful echocardiographic measure of ventricular function in adults and children. Most studies have used pulse or tissue Doppler imaging to calculate this index. M-mode, with its higher frame rate and sharp deflections, may be an accurate method of calculating the Tei index. Methods M-mode and pulse Doppler (PD) measurement of the Tei index were performed in 68 children. The mitral closure to opening time ("a") and ejection time ("b") intervals for calculating the Tei index were measured by M-mode and PD methods. Results Both M-mode and PD were found to be reproducible methods of calculating the Tei index. There was a close correlation between measurements of the "a" and "b" intervals by M-mode and PD, with less variability with M-mode than with PD. Conclusion M-mode is a simple, reproducible echocardiographic alternative method for calculating the Tei index in children and has a lower variance than PD.

Background Myocardial performance index (MPI) has been shown to be a reliable indicator of ventricular performance. This study determined MPI values in pediatric patients after cardiac transplantation without endomyocardial rejection. Methods MPI was determined in 41 pediatric patients after cardiac transplantation, without evidence of microscopic rejection, and in 31 pediatric control subjects. Results MPI in the transplantation group (0.41 ± 0.12) was higher than in the control group (0.31 ± 0.09; P = .0003). Isovolumic relaxation time and isovolumic relaxation time/ejection time were higher in the transplant group (55 ± 20 milliseconds and 0.22 ± 0.07, respectively) compared with the control group (41 ± 10 milliseconds and 0.16 ± 0.06, respectively; P = .0002). Isovolumic contraction time and isovolumic contraction time/ejection time were similar in the transplant group (48 ± 23 milliseconds and 0.19 ± 0.09, respectively) and control group (43 ± 21 milliseconds and 0.16 ± 0.08, respectively; P = not significant). Conclusions Pediatric patients after cardiac transplantation without endomyocardial rejection have a higher MPI compared with a normative pediatric control population. The difference appears to be related to abnormal diastolic function.

Despite its clinical use as a sensitive measure of left ventricular performance, little is known about whether the Tei index is influenced by aging. We determined the Tei index in 141 subjects without cardiovascular disease (age 16-78 years). There were statistically significant variations in ejection time, isovolumic relaxation time, and the Tei index with aging. There was a moderate linear correlation between isovolumic relaxation time and age (r = 0.49, P

The magnitude of left-to-right shunt in 55 children with isolated congenital heart disease [atrial septal defect (ASD) or ventricular septal defect (VSD) (muscular and perimembranous)] was estimated by two methods: radionuclide quantification and Doppler echocardiography [flow (L/min) = mean velocity × area × ejection time × heart rate]. We found little difference between the magnitude of left-to-right shunt obtained with Doppler echocardiography and that with radioangioscintigraphy for a whole group of patients (N= 55, −11.42% to 12.04%) and for subgroups of ASD (n= 24, −12.49% to 12.19%) and VSD (n= 31, −10.69% to 12.23%). These results indicate that Doppler echocardiography, in comparision with radioangioscintigraphy, is sufficiently accurate for clinical estimation of the Q p/Q s ratio in isolated congenital heart disease with left-to-right shunt.

Left ventricular (LV) performance can be evaluated noninvasively by determination of systolic time intervals including the preejection period (PEP) of the left ventricle and the ratio of the LV preejection period/LV ejection time (PEP/LVET).1–5 To our knowledge, no new systolic time interval with a sufficient potential for predicting LV performance has been widely used clinically since the inception of the PEP and PEP/LVET. In this study we evaluated LV performance using a new systolic time interval obtained by continuous-wave Doppler echocardiography and electrocardiography. In addition, we compared the effectiveness of this new systolic time interval with that of the established time intervals for evaluating left ventricular performance.

Neurologic complications are already well documented after cardiopulmonary bypass (CPB) procedures in neonates and infants. Physiologic pulsatile flow CPB systems may be the alternative to the currently used steady-flow CPB circuits. In addition to the pulsatile pump, a membrane oxygenator should be chosen carefully, because only a few membrane oxygenators are suitable for physiologic pulsatile flow. We have tested four different types of neonate-infant membrane oxygenators for physiologic pulsatility with The University of Texas neonate-infant pulsatile CPB system in vitro. Evaluation criteria were based on mean ejection time, extracorporeal circuit (ECC) pressure, and upstroke of d p/d t. The results suggested that the Capiox 308 hollow-fibre membrane oxygenator produced the best physiologic pulsatile waveform according to the ejection time, ECC pressure, and the upstroke of d p/d t. The Minimax Plus and Masterflo Infant hollow-fibre membrane oxygenators also produced adequate pulsatile flow. Only the Variable Prime Cobe Membrane Lung (VPCML) Plus flat-sheet membrane oxygenator failed to reach the criteria for physiologic pulsatility. Depending on the oxygenator used, the lowest priming volume of the infant CPB circuit was 415 ml and the highest 520 ml.

The changes in systolic time intervals associated with postextrasystolic potentiation were studied in 48 patients whose left ventricular function was categorized angiographlcally into four groups—normal function (I) and mlld (II), moderate (III) and severe (IV) left ventricular dysfunction. Postectopic potentiation in all groups caused a decrease in preejection period/left ventricular ejection time (PEP/LVET) ratio. The greatest potentiation and decreases in PEP/LVET ratio were noted in beats where the difference in compensatory pause and coupling interval (both expressed as percent of basic cycle length [CP percent — CI percent]) exceeded 40. The decrease in the ratio was least in the normal subjects (Group I) and maximal in Group IV patients. The pattern of response of the rate-corrected left ventricular ejection time and preejectlon period was also different at the four levels of ventricular function. Marked shortening of ejection time with minimal shortening of preejection period occurred in Group I, but in Group IV patients there was marked shortening of preejection period and minimal shortening of ejection time. An intermediate response was seen in Group II and III patients. The amount of shortening of ejection time exceeded that of preejection period in Group II patients; the reverse was true in Group III patients. The group responses differed with a significance of 2 P P

Fetal systolic time intervals (pre-ejection period, iso-volumetric contraction time and ventricular ejection time) can be measured using Doppler ultrasound to detect valve movements and the fetal ECG to indicate the onset of ventricular depolarisation. Continuous recordings of FSTI, fetal heart rate and uterine activity depict changes reflecting progressive cord compression and have the potential for providing improved differentiation of late and variable decelerations. However, the continual adjustment of the ultrasound transducer required to maintain a good signal limits the technique. Recent improvements in phono indicate that this may provide a useful alternative, provided that suitable signal-processing is developed.

Discontinuation of digoxin in 56 patients with sinus rhythm who had been taking it for a long time did not produce clinical deterioration in 33 of 34 patients whose pre-withdrawal steady-state plasma-digoxin concentration was less than 0.8 ng/ml; fast atrial fibrillation developed in the other patient. 22 patients had plasma-digoxin levels between 0.8 and 2.0 ng/ml before withdrawal--of these, 7 deteriorated without digoxin (5 had atrial fibrillation, which was associated with congestive heart-failure, measurement of the pre-injection period/left-ventricular ejection time (P.E.P./L.V.E.T.) ratio suggested that digoxin did exert a sustained positive inotropic effect. Thus, successful discontinuation of digoxin was possible in 86% of the total group and was more likely when the plasma-digoxin concentration was below 0.8 ng/ml. Unexpected atrial fibrillation was the commonest development inthe 8 patients in whom digoxin withdrawal was unsuccessful.

A clinically applicable method was developed for calculating aortic valve stroke volume using the echocardiographically recorded initial and late aortic cusp separation, ejection time and amplitude of posterior aortic root motion during ejection. The formula was tested prospectively in 55 patients for whom 65 Fick [n = 26]or thermodilution [n = 39]cardiac output determinations were performed simultaneously with echocardiography. Aortic valve echograms were recorded in all patients and mitral valve echograms were also recorded in 48 of the 55 patients. Twenty patients had nonrheumatic mitral regurgitation. For the 65 studies, linear correlation (r) was excellent between the aortic valve method and Fick or thermodilution method for stroke volume (r = 0.96, standard error of the estimate [SEE]± 6 cc) and for cardiac output (r = 0.92, SEE ± 0.44 liters). Differences between cardiac output values obtained from aortic valve echograms and either Fick or thermodilution techniques ranged from −1.4 to +1.5 liters/min and were normally distributed. Ninety percent of the computed aortic valve data was within 15 percent of the Fick or thermodilution data. Aortic valve stroke volume correlated well (r = 0.93) with stroke volume derived from mitral valve echograms in the patients without mitral regurgitation but did not correlate well (r = 0.78) in the patients with mitral regurgitation. Mitral valve stroke volume exceeded aortic valve stroke volume by more than 20 percent in 19 of the 20 patients with mitral regurgitation compared with 1 of 28 patients without mitral regurgitation. The presence or absence of ventricular dyssynergy did not alter statistical findings. Data from this study show that (1) aortic valve echograms can be used clinically to measure forward stroke volume, and (2) the difference between mitral valve and aortic valve volume should be a measure of mitral regurgitant flow.

Fifteen patients with idiopathic hypertrophic subaortic stenosis had a ventricular extrasystole induced with a new external mechanical cardiac stimulator during noninvasive evaluation of left ventricular outflow tract obstruction. Ten patients were monitored with simultaneous echocardiogram, phonocardiogram and indirect carotid pulse tracing; five were monitored with the phonocardiogram and indirect carotid pulse tracing alone. Nine of the 15 patients showed obstruction in the beat after the ventricular extrasystole, as defined by appearance of the characteristic bifid carotid pulse contour and, where recorded, an increase in systolic anterior motion of the mitral valve on echocardiography. Six patients did not show obstruction. All nine patients with obstruction had greater than 20 msec prolongation of uncorrected systolic ejection time in the post-extrasystolic beat of the carotid pulse tracing. Change in the uncorrected ejection time was + 0.038 +/- 0.15 second (mean +/- standard deviation) in these nine patients compared with -0.003 +/- 0.005 second in the six not showing obstruction (P less than 0.01). Six patients underwent cardiac catheterization: Three patients without obstruction after a noninvasively induced ventricular extrasystole had no obstruction at catheterization and three patients with obstruction after noninvasively induced ventricular premature beats demonstrated obstruction at rest or after provocative maneuvers during catheterization. These results indicate that the noninvasive induction of a ventricular extrasystole is a useful and easily performed procedure for both diagnosing and evaluating the dynamic left ventricular outflow tract obstruction of idiopathic hypertrophic subaortic stenosis.

In 20 consecutive patients with echocardiographic pericardial effusions and no pulsus paradoxus or other signs of cardiac embarrassment the left ventricular ejection time fell (delta LVET) during inspiration by 18.3 +/- 2.47 (SE) ms, greatly exceeding mean inspiratory delta LVET in normal subjects (7.0 ms). Median and mode delta LVET were each 15.0 ms, with delta LVET less than 10 ms and more than 25 ms in only 1 patient each. With a single exception, the magnitude of the abnormal delta LVET was least in patients with minimal to small effusions. Ejection time indices were normal during expiration and low during inspiration, indicating diminished stroke volume during inspiration only. Thus, even without clinical and echocardiographic signs of cardiac compression, the presence of pericardial fluid clearly exaggerated respiratory effects on left ventricular function but not to the degree characteristic of overtly compressing (tamponading) fluid. The consistent exaggeration of delta LVET during even small pericardial effusions is thus of physiologic interest and may be of diagnostic value.

A comparison of echocardiography with cineangiocardiography in estimating left ventricular dimensions and volumes was undertaken in 43 patients classified into four groups according to the pathophysiology of the left ventricle. There were high correlations between echographic and angiographic ventricular minor axis dimensions, however, when minor axis dimensions were more than 5.0 cm, there were underestimations of minor axis dimensions by echography.From the mean value of long-to-short axis ratio of the left ventricle at end-diastole and end-systole, the following equations were derived for calculating left ventricular volumes from echo dimensions alone : EDV=0.837 Dd3, ESV=0.994 Ds3. That these equations allowed relatively accurate prediction of volumes over a wide range of ventricular sizes was confirmed by comparison with Pombo's formula and Fortuin's formula for calculating left ventricular volume by echo dimensions alone.A comparison of echographic and cineangiographic ejection fraction (EF), relative changes in shortening of internal diameter (△S), and the mean velocity of circumferential fiber shortening (mean Vcf) was made in 33 patients with sinus rhythm. There were significant correlations between echographic and cineangiographic measurements. These was also good correlation between EF and mean Vcf by echocardiography, except one discordant patient with aortic insufficiency who showed decreased mean Vcf in the face of normal EF, all these results were confirmed by cineangiography. This discrepancy between EF and mean Vcf was ascribed to the prolonged ejection time which characterizes aortic insufficiency.

This study was undertaken to define the relation between the extent of left ventricular (LV) hypertrophy and ventricular systolic performance in patients with chronic systemic hypertension. Ninety patients with chronic systemic hypertension were compared with. 41 normal subjects as determined by anglography. LV mass was estimated from the M-mode echocardiogram. Patients were separated into 3 groups: those with LV mass of less than 2 (group I, n = 58), 2 to 4 (group II, n = 21) and more than 4 (group III, n = 11) standard deviations above mean normal. The ratio of preelection period to LV ejection time (PEP/LVET), percent shorten of the echocardiographic Internal diameter (% Δ D) and velocity of circumferential shortening (Vcf) were used as Indexes of LV systolic performance. The frequency of abnormality, expressed as percent of patients in groups I, II and III, was 33%, 55% and 85% for PEP/LVET, 15%, 35% and 72% for % Δ D, and 0%, 15% and 55% for Vcf. For each group PEP/LVET was the most frequently abnormal measure and Vcf was the least frequent abnormality. Calculation of speak and end-systolic wall stress was used as an index of the adequacy of LV hypertrophy. This index was significantly reduced in group I, did not differ from control in group II and was significantly increased in group III, indicating that hypertrophy was appropriate to wall tension in groups I and II. It is concluded that the occurrence of LV dysfunction with increasing LV mass in patients with moderate LV hypertrophy (group I and II) reflects a deficiency in intrinsic contractile performance of the hypertrophied myocardium. With a marked increased in LV mass (group III), inadequacy in LV hypertrophy relative to wall tension may also contribute to LV dysfunction.

Sixty-two patients with isolated aortic valvular stenosis were analyzed by a series of common noninvasive procedures and by cardiac catheterization. The data from 50 of these were evaluated in a retrospective fashion by multiple regression methods to determine significant objectively obtained predictors of aortic-left ventricular gradient and valvular area. Formulae were derived from these analyses and an additional 12 patients were then studied prospectively to evaluate the validity of the predictive formulae. Forty-three of 50 patients (86 per cent) were correctly identified as to a gradient of greater or less than 50 mm. Hg in the initial group, and all those in the prospectively studied sample were correctly classified. Thirty-five of 43 patients (82 per cent) of those with valve area data in the first application were correctly classified as to valve area of greater or less than 0.8 cm. 2 , and all patients in the prospectively studied group were appropriately identified as to the same area. The combined application of the observations of calcification of the aortic valve, shudder waves on the anacrotic limb, prolonged time to peak of the percussion wave and alteration of the dicrotic notch of the carotid pulse tracing, left ventricular hypertrophy by electrocardiogram, and the altered duration of ventricular ejection time were reliable predictors fo elevated aortic-left ventricular gradient and decreased aortic valvular size.

The relation between changes in left ventricular systolic time intervals with amyl nitrite (AN) inhalation and the severity of coronary artery disease (CAD) was evaluated in 77 patients who underwent catheterization because of chest pain. In 25 subjects with normal coronary angiograms (control group), AN inhalation increased the ejection time (ET), shortened the preejection period (PEP) and increased the ET/PEP markedly. In the 52 patients with CAD (CAD group), the ET/PEP changed insignificantly after AN. The difference between the 2 groups was significant (p less than 0.001). At cardiac catheterization, the increase of left ventricular dP/dt after AN in the control group was significantly larger than that in the CAD group. Although a positive correlation between changes in ET/PEP with AN and ejection fraction at rest was noted in patients with 1-vessel CAD, no such correlation was noted in those with multivessel CAD. This suggests that factors in addition to pump function, such as the degree of CAD, influence the effect of AN inhalation on systolic time intervals. When an increase of less than 30% in ET/PEP occurs with AN inhalation, the presence of significant CAD can be detected with a sensitivity of 92%, a specificity of 84% and the predictive value of 92%. The AN inhalation test is safe and simple, and thus could serve as a stress test for evaluating the presence and severity of significant CAD.

The use of indirect axillary pulse tracings was investigated as an alternative method to record the carotid pulse in infants and young children. Simultaneous high-speed recordings of ascending aortic pressure and indirect axillary pulse tracings with noninvasive peripheral blood pressures were recorded in 30 young children (aged 1 day to 48 months, median 9 months) during cardiac catheterization. In 15 patients, simultaneous left ventricular (LV) M-mode echocardiograms and phonocardiograms were also performed. Systolic ejection time (SET) and the half-time of the pulse upstroke determined by both methods were compared. Computer analysis of digitized echocardiographic and pulse tracing data was used to generate plots of LV wall stress throughout ejection. Values for wall stress derived from calibrated indirect axillary pulse tracings were compared with those derived from central aortic pressure. SET calculated from axillary tracings was within 5% of the aortic value in 91% of cases, with a mean error for all subjects of —1 ± 3%. The half-time of the pulse upstroke was within 15% of the aortic value in 91% of cases, with a mean error for all subjects of 6 ± 12%. LV wall stress was compared at the onset of ejection, peak wall stress, midsystole, and endsystole for each patient, and 98% of values calculated from axillary data were within 10% of the wall stress values calculated from aortic pressure measurements. Thus, indirect axillary pulse tracings provide an excellent representation of the aortic pressure contour and can be used for accurate calculation of SET. When combined with noninvasive blood pressure recordings and echocardiography, LV wall stress throughout ejection can be estimated accurately. These methods should be useful in advancing the understanding of myocardial mechanics in this age group.

Results of measurements of systolic time intervals (STI) in 32 patients of chronic severe anemia, before and after treatment, were studied. The patients were all without any clinical, radiological, or electrocardiographic evidence of cardiac decompensation. Data from an equal number of normal age and sex matched control subjects were also analysed. STI in individual patients showed a wide variation which precluded specific diagnostic utility. As a group, however, anemic patients showed significant differences from normal control subjects. Significant differences between pre-treatment and post-treatment values also suggest that chronic severe anemia adversely affects cardiac contractile function. Of the various STI measurements, PEP and PEP/LVET ratio were found useful parameters to be studied.

Transcutaneous recordings of carotid arterial tracings were made in 14 patients with aortic valvular stenosis, 5 with aortic insufficiency, and in 30 normal subjects. The presence of aortic valvular disease was confirmed by operation in all cases. The group with aortic valvular stenosis had marked abnormalities in the carotid tracing, the most important being the prolonged corrected ejection time. After aortic valvular replacement, the corrected ejection time decreased in all but 1 case. In addition, significant change occurred in the “u” time and “t” time in the postoperative tracings. In 5 patients with aortic insufficiency, the corrected ejection time decreased in all cases postoperatively. There were no remarkable changes in the “u” and the “t” time. We believe that this method provides a sensitive index of the hemodynamic improvement in patients subjected to aortic valvular replacement with a ball valve prosthesis. Its main advantages are its simplicity and utility as a nontraumatic, noninvasive approach to the study of ventricular function in patients with this condition. These measurements can be made repeatedly on the same patient as a simple office procedure without performing elaborate and costly cardiac catheterization procedures.

Systolic time intervals were measured in 27 normal newborn infants before and after administration of oral digoxin (30 µg/kg). Systolic intervals were also measured in 10 newborns and infants with congestive heart failure before and after this same 30 µg/kg dose of digoxin, but also after administration of a much larger "digitalizing dose" of 80 µg/kg. Preejection period (PEP) shortened significantly in the normal newborns following the smaller dose. Changes in ejection time (ET) were much less striking and appeared to be transient, lasting less than 8 hours. When small doses of digoxin were given to the babies with congestive failure, PEP again shortened significantly. In general, the larger doses of digoxin produced no further changes in PEP or ET, although there were individual exceptions. The demonstration that maximal inotropic effect, as measured by PEP changes, usually occurred with small doses of digoxin may have significant clinical implications in terms of present concepts of loading doses of digitalis in the pediatric age group.

The pre-ejection period and ejection time index were determined at rest and immediately after exercise in 39 healthy subjects and 17 patients with atherosclerotic heart disease. They were classified on the basis of health and physical activity status as sedentary healthy, active healthy, sedentary cardiac and active cardiac. The pre-ejection period at rest was longer in the sedentary and active cardiac groups than in the sedentary and active healthy groups ( P P P

Tension period, isometric contraction time and ejection time were measured in 20 normal subjects and 72 patients with nonvalvular heart disease to evaluate the usefulness of the duration of left ventricular systoles as an index of the ventricular performance. Left ventricular function could not be manifested with only one of those durations. The ratio of ejection time to isometric contraction time demonstrated a parallelism to changes in left ventricular performance. Serial observations of this ratio offer a convenient detection for the changes in left ventricular per-formance.

I N a PREVIOUS paper’ we reported abnormalities of the indirect carotid tracing in patients with aortic valvular stenosis, and we confirmed some of the findings previously described in the literature.2-12 The described findings, consistently present in all patients with this valvular lesion, consisted of prolonged total ejection time and upstroke time, carotid shudder, low anacrotic notch and an inconspicuous dicrotic notch. At that time we also indicated that 2 of our cases with subaortic stenosis presented distinct characteristics in the carotid tracing which were quite different from those in the cases with the valvular type of aortic obstruction. The purpose of this present report is to analyze in more detail the abnormalities of the carotid tracings in patients with subaortic stenosis and in cases of idiopathic myocardial hypertrophy.

Measurement of isometric contraction and ejection time by vibrocardiogram of anesthetized dog

Characteristic changes in the systolic intervals of the left ventricle have been demonstrated among patients with arteriosclerotic, hypertensive and primary myocardial disease. These consist of a prolongation of the pre-ejection period and an abbreviation in the ejection time, while total electromechanical systole remains unaltered. The changes in the pre-ejection period and the left ventricular ejection time correlate well with the level of cardiac output and stroke volume. The ratio of the pre-ejection period to the left ventricular ejection time (PEP/LVET) lends a convenient expression of these changes in the systolic intervals. The ease with which these measures can be obtained, using a noninvasive technic, suggests their use in the bedside evaluation of cardiac performance in man.

The relationship of ejection time to heart rate was examined in 19 ath-letes, 21 sedentary normal subjects and 19 patients with anginal ischemic heart disease.Exercise tests were performed using the step test, the bicycle ergometer and the treadmill. Regression analysis was applied to the data by regressing ET on HR and delta ET on delta HR.No significant differences were demonstrated between these groups even though the coronary insufficient patients manifested ischemic S-T segment changes and angina. Slight differences existed between the normal and is-chemic groups when the delta ET-delta HR relationship was examined, but the variance of the data challenged the significance.The data indicated that at any level of heart rate induced by exercise, the measurement of ejection time will not distinguish between trained athletes, normal sedentary subjects or coronary insufficient patients.

A blinded, multiple-observer comparison of ejection periods obtained from simultaneous carotid pulse tracings and digital plethysmograms was made in 10 healthy volunteers. The technique for measuring the left ventricular ejection time from the plethysmographic curve consists of the extrapolation of the rapid ascent toward the base line to obtain the upstroke point ( u ) and extrapolation of the rapid descent, preceding the dicrotic notch, to obtain the d point, analogous to the carotid incisura. A high degree of correlation with a high reciprocal predictability was found for both methods of obtaining the ejection time. The mean value of peripheral pulse transmission velocity was found to be in close agreement with those obtained by other investigators.