Inhomogeneous contribution of late diastolic filling to filling volume in patients with isolated disease of the left anterior descending coronary artery Assessment with radionuclide ventriculography.
Takashi YamagishiMASAHARU OZAKITASHIAKI KUMADAT IkezonoTATSURO SHIMIZUYuji FurutaniHiroshi OgawaYASUO MATSUDAAKIMITSU ARIMAR Kasukawa
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Abstract:
Contributions of late diastolic filling (slow filling and atrial systolic phases) to total filling volume in both global and regional left ventricle were analyzed using radionuclide techniques in 21 patients with isolated left anterior descending coronary artery disease without previous myocardial infarction. A computer program subdivided the image of the left ventricle into four regions at a geometric center of the area. The time-activity and its first-derivative curves of the global and regional left ventricles were computed. In the global left ventricle, the percent contributions of late diastolic filling to total filling volume were significantly increased in patients with one-vessel disease than in control subjects (20±5%, 28±4%; p<0.001). In the regional left ventricle, in patients with one-vessel disease, the percent contributions of late diastolic filling to total filling volume were significantly increased in the septal (25±5%, 34±8%; p<0.001) and in the apical regions (21±4%, 28±4%; p<0.001) which were perfused by stenosed vessel. In contrast, there were no significant differences in this value between the two groups in the normally perfused lateral region (226%, 255%; p=NS). These results indicate that the late diastolic filling makes a larger contribution to the left ventricular filling in the affected regions than in the normally perfused regions, and that the increased late diastolic filling in the affected regions are the cause for the increased late diastolic filling in the global left ventricle in patients with one-vessel disease.Keywords:
Ventricular filling
The pattern of left ventricular (LV) filling can be determined by Doppler echocardiography. Normally most LV filling occurs early in diastole, with some additional filling occurring during atrial systole, late in diastole. In the absence of mitral stenosis, three patterns of LV filling indicate progressively greater diastolic dysfunction: (1) Reduced early diastolic filling with a compensatory increase in importance of atrial filling, termed a pattern of "impaired relaxation;" (2) "pseudo-normalization" with most filling early in diastole but with rapid deceleration of mitral flow; and (3) "restricted filling" with almost all filling of the LV occurring very early in diastole in association with very rapid deceleration of mitral flow. A large, prolonged atrial regurgitant flow in the pulmonary veins also indicates impaired diastolic performance. The time for early filling deceleration is predominantly determined by LV stiffness: the shorter the deceleration time, the stiffer the LV. Patients with short deceleration time have a poor prognosis.
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Left ventricular diastolic function is a broad term which refers to a group of complex processes which interact to determine the resistance to filling of the left ventricle.'Impairment in one or more of these processes may increase the resistance to filling and result in the need for raised filling pressures to maintain filling and cardiac output.Because of its complex and multifactorial nature "diastolic function" is dif- ficult to assess in patients.Doppler echocardiography has emerged as a powerful non-invasive tool to assess the characteristics of left ventricu- lar filling, producing insight into diastolic function and its effect on filling pressures.This section will review the multiple interrelated factors which affect diastolic function and how Doppler echocardiography can be used to assess diastolic filling of the left ventricle.The interpretation of the various Doppler filling velocity curves as well as the practical utility of Doppler in the assessment of filling pressures and prognosis will be discussed.
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Diastolic function was evaluated in 13 patients with hypertrophic cardiomyopathy and 10 normal subjects of comparable age. Time-activity curves were used to derive peak filling rate, time to peak filling rate and average filling velocity during the first third of diastole. Left ventricular ejection fraction was significantly higher in patients with hypertrophic cardiomyopathy. Time to peak filling rate and filling velocity during the first third of diastole were significantly lower in patients compared to controls. Thus, radionuclide techniques can be used to evaluate diastolic filling in clinical practice.
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Thirty patients were prospectively studied to assess the value of radionuclide ventriculography (RNV) during step-wise dobutamine infusion for the detection of coronary artery disease (CAD). Radionuclide ventriculography was performed under basal conditions and during dobutamine infusion at each 10 μg kg-1 min-1 dose increment from 10 to a maximum of 40 μg kg-1 min-1. The test response was considered positive if the ejection fraction (EF) decreased by more than 5% or if segmental contraction abnormalities developed. Dobutamine stress testing was well tolerated, no complications and no significant arrhythmia were observed. In nine of 11 patients without CAD, EF increased more than 5% of the rest value and the left ventricular wall motion was normal in 10 of them during dobutamine infusion (specificity 91%). In 18 of 19 patients with CAD, new wall motion abnormalities (WMA) were identified in segments corresponding to the arterial lesions diagnosed by angiography (sensitivity 94%). Ejection fraction response was significantly different in normal subjects and in patients with CAD: 11 ± 5.9% versus 1.9 ± 9.5% (P < 0.01). However, abnormal EF response was found in seven of 19 CAD patients and development of new WMA was found to be a more sensitive and specific parameter than EF response for dobutamine RNV. It is concluded that dobutamine RNV is an accurate, widely available and cost-effective test for detecting CAD, especially in patients unable to exercise.
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Radionuclide ventriculography (RNV) was used to assess the peak filling rate (PFR) in 20 patients with coronary artery disease (CAD). Dipyridamole RNV was used in 5 normal subjects and 10 patients with CAD with the view to evaluating PFR increase. Significant difference in PFR values was established between normal subjects and CAD patients. Decreased value of PFR was found in 78% CAD patients, and 72% of them had normal ejection fraction (EF). During dipyridamole RNV increase of PFR was not significantly different between normals and CAD patients. The peak filling rate is a very sensitive indicator of LV dysfunction in CAD patients, and is useful in early detection of abnormalities in diastolic function in CAD patients.
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