Clin. Cardiol. 20,47-54 (1997) Transesophageal Pulsed Doppler Echocardiographic Evaluation of Left Atrial Systolic Performance in Hypertrophic Cardiomyopathy: Combined Analysis of Transmitral and Pulmonary Venous Flow Velocities TAKASHIOM, M.D., ARATAIUCHI, M.D., TOMOTSUGUTABATA, M.D., HIROTSUGUYAMADA, M.D., WUYO MANME, M.D., YOSHIMI KAGEJI, M.D., MLHO hE,M.D., NOBUOFUKUDA, M.D.,* SUSUMU ITO, M.D. The Second Department of Internal Medicine, Tokushima University School of Medicine, Tokushima; *Institute for Clinical Research, Zentsuji National Hospital, Zentsuji, Kagawa, Japan Summary Results: Left atrial dimension in Group B was significantly greater than that in the other HC groups and the control group. Background: Hypertrophic cardiomyopathy (HC) is char- Furthermore, left atrial volume changes during atrial systole acterized by impaired left ventricular (LV) diastolic function in Group B were significantly smaller than those in the other due to an increase in LV wall thickness. The severity of this HC groups and the control group. Peak atrial systolic PVF ve- disease varies depending on the localization and extent of the locity in Group B was significantlyhigher than that in the con- hypertrophied myocardium and the presence and extent of trol group and in Group C. The duration of the atrial systolic myocardial disarray or fibrosis. waves of the TMF and PVF in Group B was significantly Hypothesis: The purpose of this study was to examine the shorter and longer, respectively, than that in Group A. Left background of hemodynamic abnormalities between the left ventricular end-diastolicpressure (LVEDP) decreased in de- atrium and the left ventricle during atrial systole in patients scendmg order with Group B > Group C > Group A. In all pa- with HC using pulsed Doppler echocardiography. tients there was a significantpositive correlation between the Methods: Hemodynamic abnormalities between the left LVEDP and peak atrial systolic PVF velocity or the difference atrium and left ventricle during atrial systole were evaluated in in duration between the atrial systolic waves of PVF and patients with HC using transmitral flow (TMF) and pulmon- Th4F. Plots of these values shifted toward the left and inferior- ary venous flow (PVF) velocities obtained by transesophageal ly in Group A, and toward the right and superiorly in Group B. pulsed Doppler echocardiography. The study population in- Conclusion: Peak velocity and duration of TMF and PVF cluded 50 patients with HC, including 39 with asymmetric during atrial systole by transesophageal pulsed Doppler echo- septal hypertrophy and 11 with apical hypertrophy, and show- cardiography are useful indices of hemodynamic abnormali- ing fractional shortening of the left ventricle 230%. They ties between the left atrium and the left ventricle during atrial were classified into three groups: (1) Group A (n = 11):the ra- systole, particularly a forceful atrial contraction mismatched tio of the late to early TMF velocity < 1, and peak atrial sys- to the left atrial afterload and seventy of LV diastolic dys- tolic PVF velocity (PVA) c 25 mm/s; (2) Group B (n = 13): function, in HC. their ratio < 1, and PVA 2 25 mm/s; and (3) Group C (n = 26): their ratio 2 1. The mean age of patients in Group A was low- er than that in Groups B and C. Key words: left atrial systolic performance, hypertrophic car- diomyopathy, cpansmitral flow, pulmonary venous flow, trans- esophageal pulsed Doppler echocardiography Address for reprints: Introduction Takashi Oki, M.D. The Second Department of Internal Medicine Hypertrophiccardiomyopathy (HC) is characterizedby im- Tokushima University School of Medicine paired left ventricular (LV) diastolic function due to an in- 2-50 Kuramoto-cho crease in LV wall The severity of this disease Tokushima 770, Japan varies depending on the localization and extent of the hyper- Received: May 6,1996 trophied myocardium and the presence and extent of myocar- Accepted with revision: August 13, 1996 dial disarray or fibrosis?. 14-17 With the recent development of 48 Clin. Cardiol. Vol. 20, January 1997 transthoracicand transesophagealpulsed Doppler echocardie The transesophageal transducer was manipulated to obtain graphy, transmitral flow (TMF) and pulmonary venous flow a long-axis view of the left ventricle, placing the sample vol- (PVF) velocities now can be clearly recorded, and several ume at the tip of mitral valve leaflets to record the highest ve- studies have been published OII LV diastolic dysfunction using locity of TMF. The probe was then slightly withdrawn and these non- and semi-invasive method^.'^-^^ turned to the left to obtain a clear view of the left upper pul- The purpose of this study was to examine the background monary vein as it emptied into the left atrium. A sample vol- of hemodynamic abnormalities between the left atrium and ume then was placed 1-2 cm into the pulmonary vein. Color the left ventricle during atrial systole, particularly left atrial af- flow imaging was used to obtain a beam direction as parallel terload mismatch and severity of LV diastolic dysfunction, in as possible to venous flow. Flow velocities were recorded on patients with HC using TMF and PVF velocities obtained by a strip-chart recorder at a speed of 50 and/or 100 mdswith transesophageal pulsed Doppler echocardiography. simultaneous electro- and phonocardiogram tracings. The isovolumic relaxation time (IRT) between the aortic component of the second heart sound on the phonocardiogram Methods and the onset of early TMF (TMF-E), the deceleration time (E-DT) from the peak early TMF to the baseline, and the peak Study Patients velocities (TMF-A and PVA, respectively) and durations (TMF-Ad and PVAd, respectively) of both the atrial systolic waves of the TMF and PVF were measured by pulsed Doppler We selected 64 patients (25 women and 39 men, mean age echocardiography (Fig. 1, TMF and PVF). Interatrial septal 48 +. 19 years) with HC in sinus rhythm from 150 consecutive motion was recorded on the horizontal sections, including the patients with cardiovascular disease diagnosed by routine right and left atria, by transesophageal M-mode echocardiog- echocardiography and diagnostic catheterization in our hospi- raphy, and left atrial dimensions immediately before and after tal between July 1993 and February 1996. All patients were atrial systole (LADd and LADS, respectively) were deter- receiving no treatment at the time of the study. Ten patients mined. Volume changes in the left atrium during atrial systole with moderate to severe mitral regurgitation as determined by (LkAV-A) were determined using the equation proposed by left ventriculography and/or color Doppler flow mapping the following formula27(Fig. 1, IAS): were excluded from this study, as mitral regurgitation can sig- nificantly affect the pattern of LV filling. The remaining 54 A LAV-A = 0.94 (LADd'.24-LAD~'.24) subjects consisted of 39 patients with asymmetric septal hy- pertrophy and a fractional shortening of the left ventricle 2 30% by transthoracic M-mode and two-dimensional (2-D) echocardiography, 11 patients with apical hypertrophy of the Japanese type as demonstrated by 2-D echocardiography and TMF PVF IAS left ventric~lography~~and a fractional shortening2 30%,and IRT E-DT TMF-Ad 4 patients with asymmetric septal hypertrophy with fractional S shortening ~30%.~~Eight patients with asymmetric septal hy- pertrophy had LV outflow obstruction. The control group con- sisted of 25 subjects (11 women and 14 men, mean age 42 f 8 years) who showed no significant organic cardiovascular dis- ease after echocardiography and cardiac catheterization for chest pain, dyspnea, or heart murmurs on auscultation. ECG d- mi8.-- @- A- Study Design c ?. ' PCG- PCG PCG lla The purpose of the examination was fully expl@nedto all FIG.1 Parameters of transmitral flow (TMF) and pulmonary ve- subjects, and informed consent and approval were obtained. nous flow (PVF) velocities, and interatrial septal (IAS) motion mea- sured by the transesophageal approach. = i~ovolumicrelaxation Left ventricular end-diastolic pressures (LVEDPs) were re- IRT time between the aortic component (IL) of the second heart sound on corded with a #8.3 F fluid-filled pigtail catheter by left heart the phonocardiogram and the onset of early TMF E-DT = decelera- catheterization in all the subjects. Diazepam (5 mg) was rou- tion time from the peak early TMF to the baseline; TMF-E and -A = tinely given as premedication before catheterization.Various early diastolic wave and peak velocity of the atrial systolic wave of types of echocardiographic measurements were performed the TMF, respectively; TMF-Ad and PVAd =durations of both the within 3 h prior to cardiac catheterization.Measurements by atrial systolic waves of the TMF and PVF, respectively; PVSI and transthoracicM-mode echocardiographywere Qbtainedof the PVS:! = first and second systolic waves of the PVF, respectively; PVD =early to mid-diastolic wave of the PVF; PVA = peak velocity LV end-diastolic dimension, percent fractional shortening of of the atrial systolic PVF; LADd and LADS= left atrial dimensions the left ventricle, maximal left atrial dimension at systole, and just prior to and following atrial contraction, respectively; LA = left interventricular septal and LV posterior wall thicknesses at atrium; RA = right atrium; ECG = electrocardiogram; PCG = end-diastole. phonocardiogram. T. Oki et al. : Left atrial systolic performance in HC 49 M-mode and pulsed Doppler echocardiograms were (Fig. 5), and (4) 13 patients (Group B) with a PVA 2 25 mds recorded with commercially available Toshiba SSH-65A (Fig. 6). (Toshiba Corp., Tokyo) and Aloka SSD-870 (Aloka Co., Table I shows the age, atrial systolic parameter of the TMF, Ltd., Tokyo) ultrasound diagnostic systems using a 2.5-MHz PVF and interatrial septal motion, and LVEDP in the control transthoracic probe and a 5-MHz transesophageal probe, re- group and the four groups with HC. The mean patient age in spectively. Each subject was premedicated with 1% lidocaine Group A was significantly lower than that in Groups B, C, and spray applied to the posterior pharynx for the transesophageal D (all p < 0.0o01).