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|Year : 2023
: 26 | Issue : 1 | Page
|Elastic recoil signal on tissue doppler imaging of mitral annulus as a qualitative test to identify left ventricular diastolic function
Deepak Prakash Borde1, Devarakonda Bhargava Venkata2, Shreedhar Joshi3, Amish Jasapara4, Pooja Joshi1, Balaji Asegaonkar1
1 Cardiac Anaesthesia, Ozone Anaesthesia Group, Aurangabad, Maharashtra, India
2 Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
3 Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Hospitals, Bengaluru, Karnataka, India
4 Cardiac Anaesthesia, Fortis Hospitals, Mumbai, Maharashtra, India
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|Date of Submission||14-Feb-2021|
|Date of Decision||13-May-2021|
|Date of Acceptance||19-May-2021|
|Date of Web Publication||03-Jan-2023|
| Abstract|| |
Introduction: Left ventricular (LV) diastolic dysfunction is common on preoperative screening among patients undergoing surgery. There is no simple screening test at present to suspect LV diastolic dysfunction. This study was aimed to test the hypothesis, whether elastic recoil signal (ERS) on tissue Doppler imaging of mitral annulus (MA TDI) can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction.
Methods: This was a prospective cross-sectional observational study of patients admitted for elective surgeries. Normal diastolic function and categorization of LV diastolic dysfunction into severity grades I, II, or III were performed as per the American Society of Echocardiography/ European Associationof Cardio Vascular Imaging (ASE/EACVI) recommendations for LV diastolic dysfunction.
Results: There were 41 (61%) patients with normal LV diastolic function and 26 (39%) patients with various grades of LV diastolic dysfunction. In 38 out of 41 patients with normal LV diastolic function, the characteristic ERS was identified. The ERS was absent in all the patients with any grade of LV diastolic dysfunction. Consistency of identification of ERS on echocardiography was tested with a good interobserver variability coefficient of 0.94 (P-value <0.001). The presence of ERS demonstrated an excellent differentiation to rule out any LV diastolic dysfunction with an area under the receiver operating characteristics curve (AUROC) of 0.96 (CI 0.88–0.99; P value <0.001).
Conclusions: To conclude, in a mixed surgical population, the anesthetist could successfully assess LV diastolic dysfunction in the preoperative period and the characteristic ERS on MA TDI signal can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction using the transthoracic echocardiography (TTE).
Keywords: Elastic recoil signal, LVDD, POCUS
|How to cite this article:|
Borde DP, Venkata DB, Joshi S, Jasapara A, Joshi P, Asegaonkar B. Elastic recoil signal on tissue doppler imaging of mitral annulus as a qualitative test to identify left ventricular diastolic function. Ann Card Anaesth 2023;26:42-9
|How to cite this URL:|
Borde DP, Venkata DB, Joshi S, Jasapara A, Joshi P, Asegaonkar B. Elastic recoil signal on tissue doppler imaging of mitral annulus as a qualitative test to identify left ventricular diastolic function. Ann Card Anaesth [serial online] 2023 [cited 2023 Jan 30];26:42-9. Available from: https://www.annals.in/text.asp?2023/26/1/42/367011
| Introduction|| |
Left ventricular (LV) diastolic dysfunction is very common among patients undergoing surgery and it may be seen in up to two-thirds of the geriatric surgical population. In patients undergoing noncardiac surgery, LV diastolic dysfunction is significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90), myocardial infarction (OR, 1.74), and the composite outcome of major adverse cardiovascular events (OR, 2.03). Furthermore, in patients undergoing cardiac surgery, it is associated with higher mortality and morbidities like major adverse cardiac events and prolonged mechanical ventilation; independent of systolic dysfunction., A formal diagnosis of LV diastolic dysfunction according to the current American Society of Echocardiography and European Association of Cardiovascular Imaging (ASE/EACVI) update involves acquisition and analysis of multiple parameters requiring advanced training and time-consuming algorithms. According to a recent survey, among cardiac anesthesiologists, marked variation currently exists to evaluate, grade, and monitor diastolic function during cardiac surgery.
A recent review evaluated focused echocardiography performed by anesthetists and critical care physicians. The common diagnosis made in perioperative hemodynamically unstable patients were LV systolic dysfunction, valvular heart diseases, right ventricular dysfunction, or hypovolemia. There is no simple screening test at present to suspect LV diastolic dysfunction. In a proof-of-concept study, the authors demonstrated that identification of an early characteristic elastic recoil signal (ERS) occurring on the mitral annulus tissue Doppler imaging (MA TDI) right after the early filling (e') velocity was feasible. The presence of ERS in the population was distinctively seen in patients without any LV diastolic dysfunction. If anesthetists performing point-of-care ultrasound (POCUS) can screen for LV diastolic dysfunction in high-risk surgical patients, it is possible that they can make changes in the management.
This study was aimed to test the hypothesis, whether ERS on MA TDI can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction.
| Methods|| |
This was a cross-sectional observational study that prospectively evaluated consecutive patients admitted for elective surgeries in a tertiary care hospital. An institutional review board-approved study protocol and written informed consent was obtained from all patients.
Patients were enrolled with the following inclusion criteria for participation in the study: consecutive adult patients >18 years of age of either sex during December 2019 to August 2020, scheduled for elective surgeries in whom the attending anesthesiologist performed POCUS. Exclusion criteria were the following: significant valvulopathy (more than mitral regurgitation, prior mitral valve repair using ring annuloplasty, severe mitral annular calcification, mitral stenosis of any grade, and inadequate acoustic window that precluded complete delineation of left atrium [LA], or the presence of frequent arrhythmias).
The transthoracic echocardiography (TTE) was performed in the preoperative period by a single board-certified anesthetist who also was certified in the advanced focused assessed transthoracic examination. All TTE examinations were performed on a GE Vivid T8 echocardiography machine; images were recorded in a raw Digital Imaging and Communications in Medicine (native DICOM format) were analyzed offline using the EchoPAC software (version 203, GE Healthcare, Norway).
Comprehensive TTE was done as per the ASE updates. LV volumes (end-systolic and end-diastolic) were measured in the apical four-chamber view and ejection fraction (EF) was calculated by the biplane method of disks (Simpson's method). Parameters for evaluation of LV diastolic dysfunction measured were as per the 2016 ASE/EACVI update. Transmitral pulse-wave Doppler was obtained at the mitral leaflet tips in an apical four-chamber view to measure peak early (E) and late (A) diastolic filling velocities, E/A ratio, and E-wave deceleration time. Doppler tissue imaging of the MA (TDI) was interrogated at the septal and lateral positions, from which values for the peak early (e') velocities were obtained and were averaged. The method of disks technique was used to measure LA volume, which was indexed to body surface area to yield the left atrial volume index (LAVI). The maximum tricuspid regurgitation (TR) velocity was obtained in RV focused apical four-chamber view and used to generate the peak tricuspid regurgitation velocity. Normal diastolic function and categorization of diastolic dysfunction into severity grades I, II, or III were performed as per the ASE/EACVI recommendations for LV diastolic dysfunction 2016. The parameters are displayed in a representative patient in [Figure 1].
|Figure 1: Comprehensive assessment for left ventricular diastolic function as per 2016 ASE/EACVI updates in a sample patient|
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The ERS was the spectral Doppler display seen above the baseline and occurring after the MA TDI early e' and before atrial contraction (a') velocity signal [Figure 2]. Two blinded board-certified echocardiographers were provided with the echocardiography loops for identification of the presence or absence of ERS waveform of all enrolled patients to test for interobserver variation. An independent third board-certified echocardiographer stratified LV diastolic dysfunction for all the patients as per ASE updates.
|Figure 2: Identification of various signals on mitral annulus tissue Doppler imaging; e' represents early filling, a' represents atrial contraction phase of LV diastolic dysfunction while s' represents LV systolic signal. Note the appearance of characteristic elastic recoil signal (ERS) after e'|
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Continuous variables were presented as mean and standard deviation or median and range depending on the distribution. Categorical variables were presented as counts and proportions. Pearson's correlation coefficients were calculated to assess the correlation between continuous variables. Sensitivity and specificity were calculated using standard definitions, receiver operating characteristic curves (ROC) were constructed, and the area under the curve (AUC ROC) was calculated for the prediction of normal diastolic LV function based on the presence of ERS. Interobserver variability was assessed for ERS identification and measured for agreement between two investigators using kappa (k) coefficient analysis. The P value <0.05 was considered statistically significant. Statistical Package for Social Sciences version 11 was used for statistical analysis.
| Results|| |
During the study period, 72 patients were considered suitable for inclusion in the present study. Five patients were excluded for reasons of the presence of significant mitral regurgitation, mitral annular calcification, atrial fibrillation, and incomplete data to stratify LV diastolic dysfunction. The final analysis included 67 patients with various surgical categories; twenty were general surgery patients, 12 were for orthopedics procedures, 8 for urological procedures, and 27 were cardiac surgical patients. Baseline characteristics and echocardiographic parameters as per LV diastolic dysfunction grade are described in [Table 1]. There were 41 (61%) patients with normal LV diastolic function and 26 (39%) patients with various grades of LV diastolic dysfunction. In 38 out of 41 patients with normal LV diastolic function, the characteristic ERS was identified while three patients did not have this signal. None of the patients with any grade of LV diastolic dysfunction had this ERS. The AUROC (AUC ROC) of 0.96 (CI 0.880.99; P value < 0.001) was obtained for normal versus any grade of LV diastolic dysfunction [Figure 3]. For interobserver variability λ coefficient value of 0.94 (P-value < 0.001) was obtained suggesting minimal bias.
|Table 1: Baseline characteristics and echocardiographic parameters as per LV diastolic dysfunction grade|
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|Figure 3: The area under the receiver operating characteristics curve (AUROC) of 0.96 (CI 0.88–0.99; P value < 0.001) for normal vs. any grade of LV diastolic dysfunction|
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In sample 10 patients with normal LV diastolic function, the characteristic ERS was identified as shown in [Figure 4] and another 10 sample patients with various grades of LV diastolic dysfunction had this ERS absent as shown in [Figure 5].
|Figure 4: In sample 10 patients with normal LV diastolic function, the characteristic elastic recoil signal (ERS) as shown by red arrows|
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|Figure 5: In sample 10 patients with various grades of LV diastolic dysfunction as shown by numerical in circle, the elastic recoil signal (ERS) was absent as shown by red arrows|
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| Discussion|| |
The main finding of the study was that characteristic ERS on MA TDI signals can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction using TTE performed by anesthetists in preoperative settings.
Diastolic filling of the LV is a highly complex process which is dependent on LV relaxation, LV compliance, and left atrial pressure. In a demographic data study from the national echo database of Australia (enrolling 4,36,360 patients), the authors demonstrated that abnormal diastolic function defined by ASE/EACVI criteria was associated with increased risk of cardiovascular-related and all-cause mortality. This is reflected in the surgical patient population as well. In a meta-analysis of patients undergoing noncardiac surgery, LV diastolic dysfunction was significantly associated with pulmonary edema/congestive heart failure, myocardial infarction, and the composite outcome of major adverse cardiovascular events (MACE) by two-three-folds. The impact of LV diastolic dysfunction on the incidence of perioperative myocardial injury in patients undergoing noncardiac surgery is evident even in patients with preserved EF. In another unselected cohort with ambulatory surgical patients, the authors identified a substantial number of previously unknown cases of cardiac disease particularly LV diastolic dysfunction, especially in patients over 65 years of age. The grade of LV diastolic dysfunction also has an impact on outcomes. In a recent large single-center study, patients with isolated diastolic dysfunction undergoing noncardiac surgery—10.0% developed MACE after surgery; higher grade LV diastolic dysfunction was associated with greater risk.
It has become imperative for anesthetists to understand the pathophysiology, diagnosis, and management of patients with LV diastolic dysfunction. The present algorithms by ASE/EACI for assessment of LV diastolic dysfunction need multiple parameters, are complex and time-consuming which could explain the ambivalence of anesthetists toward incorporating them as part of an echocardiographic examination. Moreover, these updates are not specific for the perioperative patient population. There is an unmet need to devise a practical, quick, and simple approach for the perioperative assessment of LV diastolic dysfunction. Some attempts were made in the past but are not yet validated.,
In a proof-of-concept study, Hernandez-Suarez and colleagues demonstrated that the identification of an early characteristic ERS occurring on the MA TDI after e' velocity was feasible. This distinctive appearance of the ERS occurred only in patients with normal LV diastolic function and was absent in any grade of LV diastolic dysfunction. The mechanism of this phenomenon is as explained by the authors. The basal-to-apical atrioventricular plane displacement occurs during systole contributing to both LV ejection and LA filling. During ventricular diastole, as the atrioventricular plane returns to its initial position, the resultant hydraulic forces redistribute blood from the atria to the ventricle contributing to early LV filling. These longitudinal MA displacements have been approximated to the function of a piston. The ERS signal above the baseline occurs after this early filling on MA TDI which are represented above baseline. In our study of mixed surgical patients, we demonstrated that this ERS signal occurred in most patients with normal LV diastolic function (38/41 = 93%). Also, this signal was absent in all the patients with various grades of LV diastolic dysfunction. This yielded a statistically significant AUC ROC of 0.96 (CI 0.88–0.99; P value < 0.001) for ERS to differentiate a normal diastolic function versus any grade of LV diastolic dysfunction on ROC. Also, there was a minimal bias between observers making it an even more robust marker.
Certain precautions need to be observed when interpreting results of ERS on MA TDI as shown in [Figure 4] and [Figure 5]. The TDI is angle-dependent, hence, the angle of insonation should be less than 20°. The usual scale of ERS is around 2 cm/s suggesting that the scale of TDI be optimized around 15 cm/s. Tachycardia may preclude accurate measurement and this ERS may not be useful in patients with arrhythmia like AF. There can be significant movement during breathing and probe manipulation which is reflected on TDI signals, hence, all measurements should be measured at end-expiration.
The findings of the present study can have potential use in perioperative POCUS performed by anesthetists. If the anesthetist can identify this ERS they can be assured of normal diastolic function of LV and normal LV-filling pressures. If there is a hemodynamic disturbance, the first response can be an administration of intravenous fluids. Need for further investigations in the form of formal and detailed echocardiography and to restratify the risk is another scenario where ERS is deemed useful. This can reduce the burden on echocardiography services and help in quicker decision-making for preoperative patients.
There are certain limitations of this study. This was a single-center study enrolling a limited number of patients. As it was a qualitative assessment, the power of the study could not be determined. Also, the power of this study was limited to assess the impact of LV diastolic dysfunction parameters on outcomes. The change in LV diastolic dysfunction in the perioperative period can have bearings on LV diastolic dysfunction which was not studied. This assessment with common interventions could have improved its utility. To ascertain whether the ERS will serve the purpose of a screening parameter, it will be necessary to evaluate a large number of consecutive patients. Another, major limitation of ERS is that it is a qualitative assessment parameter, which cannot distinguish the grades of LV diastolic dysfunction.
To conclude, in a mixed surgical population, anesthetists could successfully assess LV diastolic dysfunction in the preoperative period and the characteristic ERS on MA TDI signal can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction using TTE.
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Conflicts of interest
There are no conflicts of interest.
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Deepak Prakash Borde
Department of Cardiac Anaesthesia, Ozone Anaesthesia Group, First Floor, OPD Wing, United CIIGMA Hospital, Aurangabad - 431 001, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]