Systolic And Diastolic Velocities Biology Essay

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Regional wall motion abnormalities are frequently seen in coronary artery disease and diastolic function is impaired before systolic dysfunction in these patients1. Reperfusion with percutaneous coronary intervention has been shown to improve the left ventricular systolic and diastolic function 2, 3.

Changes in the regional ventricular function may appear before alteration of global ventricular function in coronary artery disease 3.

The most recent approach to analysis of regional wall motion is with Doppler tissue imaging or speckle tissue traction4.

Systolic and diastolic velocities of cardiac cycle can be recorded quantitatively by tissue Doppler imaging and thereby provides a newer way of assessing left ventricular function which is more sensitive than traditional methods5.

Tissue Doppler imaging has a high sensitivity, high feasibility, reproducibility and ease of application in acute coronary syndrome6.

Tissue Doppler imaging is easily available in most of the centres. Tissue Doppler parameters such as Sm, Em, and Am are powerful predictors of cardiac mortality7.

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We wanted to study the changes in tissue Doppler imaging parameters before and after percutaneous coronary angioplasty as an easily available tool in Indian scenario to assess the functional improvement in left ventricular function.

REVIEW OF LITERATURE

REVIEW OF LITERATURE

J.M.Strotmann et al studied the effect of myocardial ischemia on longitudinal myocardial function in thirty patients before and after Percutaneous Transluminal Coronary Angioplasty of single vessel disease. Peak systolic velocity increased in the ischemic segments after Percutaneous Transluminal Coronary Angioplasty3.

Derumeaux et al have shown clear relationship between regional myocardial velocity and myocardial perfusion in animal models8.

Klisiewicz A et al effect of angioplasty in 39 patients 1 to 6 months after myocardial infarction. Peak systolic velocity increased and contractile reserve increased after angioplasty. Regional Em wave velocity increased 24 hours after angioplasty, but there was no increase in Am wave velocity 24 hours after angioplasty9.

Park SM et al studied 20 patients with anterior wall myocardial infarction using Doppler tissue imaging as a tool to predict myocardial viability. They showed strain rate imaging was a better predictor to show viable myocardium after percutaneous coronary angioplasty10.

Minamihaba O et al compared Pulse Doppler Tissue Imaging with 99mTc sestamibi perfusion imaging in 30 patients before and after coronary angioplasty. The peak systolic velocity was positively correlating with Tc-MIBI uptake(R=0.59,p <0.01).The PEP/ET(preejection period/ejection time) and peak systolic velocity is having higher diagnostic accuracy for detecting viable myocardium when compared with Tc-MIBI perfusion imaging(79% and 80% vs 90%)11.

Tumuklu M et al studied improvement in diastolic function after percutaneous angioplasty in 31 patients. They showed a significant increase in diastolic parameters of left ventricle i.e. Sm, increased from 11.3 ± 3.1 cm/sec to 13.2 ± 3.6 cm/sec p = 0.03;isovolumetric relaxation time(IVRT) decreased from 130 ± 37 msec to 108 ± 29 msec p = 0.0001;IVCT(isovolumetric contraction time decreased from 84.1 ± 19.2 msec to 75.6 ± 12.2 msec.12

Hasan Shemirani et al evaluated early alterations in tissue Doppler findings of the septal and lateral segments of left ventricle after coronary angioplasty in forty patients with single vessel disease. Am and Em velocity significantly improved in septum and Sm velocity does increased, but not statistically significant. This study showed diastolic function improved immediately after coronary angioplasty but not the systolic function.13

Penicka M et al analyzed 43 patients with myocardial infarction and single vessel disease. They used positive pre ejection velocity to predict recovery left ventricle contractile function. Their study showed positive pre ejection velocity measured by tissue myocardial velocity can predict recovery of ischemic myocardium.14

Myocardial perfusion imaging, Magnetic resonance imaging is the best clinical tools to assess the myocardial viability after angioplasty. They are expensive and not available in all centres.

Tissue Doppler imaging is quick quantitative method to assess the functional recovery of myocardium after coronary angioplasty.

Doppler Tissue Imaging

Doppler tissue imaging can be performed by using pulse tissue Doppler imaging, color 2D Doppler and color M mode Doppler. Tissue Doppler imaging can be used as a noninvasive tool to assess the systolic and diastolic myocardial function.15

Doppler Effect

The Doppler Effect is the phenomenon whereby the frequency of a reflected wave is altered by movement of reflecting surface away from or toward the source. The low Doppler shift frequencies of high energy generated by the wall motion are filtered out. These low Doppler shift frequencies are produced by myocardium; hence their assessment is useful to know the ventricular function.16

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Pulse Doppler technique can be used to obtain high quality Doppler signals, measuring mean and instantaneous local acceleration, rapid quantification.

The limitations of pulse TDI are

1. The need for manual mapping

2. Limited spatial resolution

3. Simultaneous recording of different segments is not possible.

The longitudinal and circumferential fibers of ventricle contribute to overall function of left ventricle. Tissue Doppler imaging is influenced by overall cardiac movement and tethering by adjacent myocardial tissues.17

The normal velocity of Em for lateral annulus is more than 15 cm/sec and septal annulus is above 10 cm/sec.This difference in velocity between lateral and septal annulus is due to different orientation of myocardial fibres.Tissue Doppler velocity is more at the base of ventricle than at mid ventricle and apex.18

Em velocity indicates myocardial relaxation. Em is low and does not increase in patients with impaired myocardial relaxation. Em is the earliest marker of diastolic dysfunction and is less in all stages of diastolic dysfunction.18

Normally Em/Am ratio is more than one .In grade I diastolic dysfunction Em is less than Am. Em and Am velocity progressively decreases from grade II to grade III diastolic dysfunction.18

Normal values of TDI

In children and young adults lateral annulus velocity is more than 20 cm/sec.

Lateral annulus velocity more than 12 cm/sec in adults above 30 years denotes normal left ventricle diastolic function.

Table No 1 showing normal values in general population19

TDI 

Septum

Lateral

Inferior

Anterior

S wave, cm

   Basal

5.97 ± 1.14

6.26 ± 2.44

6.52± 1.31

6.44± 2.32

   Mid

6.29 ± 1.89

4.48± 0.92

5.21± 2.79

5.1 ± 1.16

   Apical

4.42 ± 2.3

4.81 ± 1.97

2.97± 1.14

3.8 ± 2.66

E wave, cm

   Basal

7.91± 2.16

8.54± 2.77

9.01± 2.44

8.09± 2.48

   Mid

8.39 ± 2.5

6.85± 1.86

6.82± 3.16

7.22± 2.04

   Apical

6.03 ± 2.95

6.74± 2.58

4.76 ± 1.94

4.52± 2.95

A wave, cm

   Basal

5.99 ± 1.73

3.77 ± 1.95

5.84± 2.06

3.86 ± 1.75

   Mid

4.87± 2.14

4.9 ± 1.72

2.62± 1.84

4.78 ± 1.7

   Apical

2.69± 1.93

3.77 ± 2.1

3.08 ± 1.54

1.69± 1.45

Tissue Doppler image

Figure 1

TDI at lateral wall of LV and septal wall of LV

C:\Users\Kalyanaraman\Desktop\tdi.JPG

Uses of Doppler tissue imaging

Global left ventricular systolic function

We can quantify the movement of cardiac basal septum and basal lateral wall of left ventricle using M mode echocardiography.Quatification of movement of basal segments of ventricle can also be done using Tissue Doppler echocardiography.

Gulati et al showed that six site peak annular descent velocity correlated linearly with radionuclide ejection fraction(r = 0.86, SEE = 1.02cm/sec).20

Peak systolic velocity was less in dilated cardiomyopathy.Doppler Tissue Imaging peak systolic velocity correlated with angiographically calculated Ejection Fraction and peak dp/dt.21

Regional systolic function of ventricles

Regional myocardial velocity varies among individual segments of ventricle in normal patients.

Systolic myocardial velocity is normally high at base of ventricles than at the mid wall and apex. Systolic myocardial velocity of Lateral tricuspid annulus is more than the lateral mitral annulus velocity. Tissue Doppler imaging is useful to detect regional changes in myocardial contractility.22

Lateral annulus Systolic myocardial velocity is used to see the longitudinal left ventricle systolic function and there is linear relationship with left ventricle ejection fraction and left ventricle dp/dt.

Before and after angioplasty

Based on some studies myocardial systolic velocity was less in ischemic and infracted segments of left ventricle. With inflation of coronary balloon in coronary artery peak myocardial velocity decreases with rebound increase after deflation of balloon and reperfusion.23

Changes in systolic myocardial velocity depend on the ischemic severity and there is a relation between myocardial velocity and coronary perfusion.

Normalization of peak systolic velocity with dobutamine stress echocardiogram and exercise is a marker of viable myocardium.24

Assessment of diastolic function by Doppler tissue imaging

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Mitral inflow Doppler is preload dependant and its use to assess the diastolic dysfunction of left ventricle is limited.25

In patients with diastolic dysfunction Em velocity and Em/Am ratio was low when compared with normal individuals. Coronary artery disease patients with normal systolic function have abnormal diastolic function of left ventricle.26

Active relaxation of left ventricle

Early diastolic myocardial velocity indicates myocardial relaxation.Pre load has less effect on measuring early diastolic velocity.

Myocardial time constant of isovolumic relaxation Tau was linearly related to early diastolic velocity and Em/Am ratio.27

AIM OF STUDY

AIM OF THE STUDY

1. To evaluate the Regional Myocardial Function using Tissue Doppler Imaging before and after Percutaneous Transluminal Coronary Angioplasty.

2. To assess the extent to which these tissue Doppler indices change 24 hours before Percutaneous Transluminal Coronary Angioplasty, 24 hours after Percutaneous Transluminal Coronary Angioplasty and 3 months after Percutaneous Transcutaneous Coronary Angioplasty.

3. To evaluate how this helps to know the success of Percutaneous Transluminal Coronary angioplasty.

MATERIAL AND METHODS

MATERIALS AND METHODS

This prospective non randomized follow up study was carried out at Rajiv Gandhi Government General Hospital; Chennai.This study was done between march 2012 to January 2013.This study was approved by our institution ethical committee.

SELECTION OF STUDY SUBJECTS

INCLUSION CRITERIA

1. All patients with Stable angina with age above 30 years and both sex.

2. Patients with prior coronary angiogram showing isolated Left anterior descending coronary artery disease suitable for elective percutaneous intervention and stenting were included.

EXCLUSION CRITERIA

Patients with any of the following criteria were excluded from the study

1. Patients with Non ST Elevation Myocardial Infarction, Unstable angina, Acute ST Elevation Myocardial Infraction

2. Patients with multivessel coronary artery disease, left circumflex coronary artery disease, right coronary artery disease

3. Patients with valvular heart disease, cardiomyopathy, atrial fibrillation, prior coronary revascularization, congenital heart disease, moderate to severe left ventricular systolic dysfunction (Ejection Fraction less than 40%).

STUDY PROTOCOL

Written informed consent was obtained from all the patients and this study was approved by our hospital ethical committee. Patients with recent myocardial infarction with prior coronary angiogram showing isolated single vessel disease of Left Anterior Descending coronary artery admitted for Percutaneous Transluminal Coronary Angioplasty with bare metal stent were selected. Patients belonged to both sex and of all ages. History and physical examination was done for all patients in this study. All routine laboratory investigation was done. Patients were examined with echocardiogram 24 hours before Percutaneous Transluminal Coronary Angioplasty; 24 hours after Percutaneous Transluminal Coronary Angioplasty and 3 months after Percutaneous Transluminal Coronary Angioplasty.

ECHOCARDIOGRAPHY

Routine Echocardiographic evaluation and Tissue Doppler imaging was done for all the selected 93 patients 24 hours before PTCA,24 hours after PTCA and 3 months after PTCA.Philips XD7 with adult transducer was used to acquire images using tissue Doppler imaging software.

Echocardiographic examination is done as per recommendations of the American Society of Echocardiography. Left ventricular ejection Fraction was calculated using simplified quinones method.

TISSUE DOPPLER IMAGING

Tissue Doppler imaging of medial mitral annulus and lateral mitral annulus of Left Ventricle was performed in apical 4 chamber view within 1 cm of mitral leaflets .Using Tissue Doppler imaging software preset ,three major mitral annular velocities were recorded with angulation less than 20 degrees. Recording is done at sweep speed of 50 to 100 mm/sec at end expiration.28 Average Peak myocardial systolic(Sm wave), peak myocardial early diastolic velocity (Em wave) and peak myocardial late diastolic velocities (Am wave) of 3 values were recorded 24 hours before Percutaneous Transluminal Coronary Angioplasty; 24 hours after Percutaneous Transluminal Coronary Angioplasty and 3 months after Percutaneous Transluminal Coronary Angioplasty.

PERCUTANEOUS CORONARY INTERVENTION

Percutaneous Transluminal Coronary Angioplasty of proximal or mid Left Anterior Descending coronary artery with bare metal stenting was done using Toshiba fixed catheterization laboratory according to standard techniques. All patients had successful Percutaneous Transluminal Coronary angioplasty results with residual stenosis less than 30 %.None of the patients had any peri procedural myocardial infarction. All patients were discharged after 3-5 days with dual antiplatelets, Angiotensin Converting Enzyme inhibitors, beta blockers and statins.They were on follow up every 15 days for drugs and repeat evaluation with echocardiogram was done after 3 months. Follow up Coronary Angiogram was not done at 3 months.

STATISTICAL ANALYSIS

Statistical analysis was done using online paired two tailed t test. A two tailed p value of less than 0.05 was required for significance.

RESULTS AND OBSERVATION

RESULTS

RESULTS AND OBSERVATION

AGE AND SEX DISTRIBUTION

Table 1

Age

sex

30 - 40

41 - 50

51 - 60

61 - 70

Total

Male

12

33

30

10

85(91.3)

Female

1

3

2

2

8(8.6)

Total

13(13.9)

36(38.7)

32(34.4)

12(12.9)

93

91.3% of patients in were males and 8.6% of patients were females in this study. A youngest patient was 30 years old and the oldest patient age was 70.73 males were above the age of 40 years and 7 females were above the age of 40 years.12 males and 1 female were less than 40 years old.

13.9% belong to the age group of 30-40 years;38.7% were in the age group of 41-50 years;34.4% were in the age group of 51-60 years;12.9% were in the age group of 61-70 years.73% of patients were in the age group of 41-60 years.

Mean age of patients in this study was 50.08±18.04 years.

ASSESSMENT OF RISK FACTORS

TABLE NO 2

RISK FACTORS

MALE

FEMALE

Smoker

68

0

Diabetes mellitus

67

8

Hypertension

20

1

Diabetes mellitus, Hypertension and Smoker

8

0

Diabetes Mellitus and Smoker

35

0

Hypertension and Smoker

2

0

68 male patients were smokers in our study.67 males and 8 females have Diabetes Mellitus as risk factor.

20 male and 1 female have Hypertension as coronary risk factor.

8 patients had all the three risk factors that is Smoker, Diabetes Mellitus and Hypertension.

35 patients had two risk factors i.e. Diabetes mellitus and Smoking.2 patients had Hypertension and Smoking as risk factor of atherosclerosis.

Majority of the patients were smokers and having Diabetes Mellitus.

None of the female patient has more than one risk factor.

BASELINE CHARECTERISTICS OF ALL PATIENTS IN OUR STUDY

Table 3

Parameters

Range

Mean ± sd

Age

30-70 years

50.08 ± 18.04 years

Male -no (%)

85(91.39%)

Heart rate

50 - 94 beats per min

71.2 ± 20.92 beats per min

Systolic BP

110 - 160 mm of Hg

128 ± 25.78 mm of Hg

Diastolic BP

80 - 90 mm of Hg

80.36 ± 3.15 mm of Hg

Random blood glucose

79 - 206 mg/dl

126.22 ± 58.98 mg/dl

Blood urea

20 - 38 mg/dl

27.66 ± 6.64 mg/dl

Serum creatinine

0.4 - 1.1 mg/dl

0.81 ± 0.19 mg/dl

Bare metal stent diameter

2.5 - 3.5 mm

2.95 ± 0.54 mm

Bare metal stent length

12 - 30 mm

21 ± 9.2 mm

SD denotes Standard deviation

mg/dl denotes milligrams/deciliter and mm denoted millimeter.

The average heart rate in this study was 71.2 ± 20.92 beats per min.The average systolic blood pressure was 128 ± 25.78 mm of Hg and the average diastolic blood pressure was 80.36 ± 3.15 mm of Hg.

The minimum heart rate was 50 beats per minute and the maximum heart rate was 94 beats per minute.

Random blood glucose was 126.22 ± 58.98mg/dl.Average blood urea and serum creatinine was 27.66 ± 6.64 mg/dl and 0.81 ± 0.19 mg/dl respectively.

The mean diameter and length of the bare metal stent used in this study were 2.95 ± 0.54 mm and 21 ± 9.2 mm respectively.

Table 4

Sm velocity of basal medial septum 24 hours before PTCA, 24 hours after PTCA, 3 months after PTCA

24hour before PTCA

24 hours after PTCA

3 months after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Sm

8.498

0.421

0.044

9.068

0.424

0.044

8.992

0.431

0.045

Two tailed p value

P <0.0001

Statistically significant

P <0.0001

Statistically significant

95% CI

-0.636 to - 0.504

0.042 to 0.108

SD denotes standard deviation; SEM denoted standard error of mean

The mean Sm velocity increased from 8.498cm/sec 24 hours before Percutaneous Transluminal Coronary Angioplasty to 9.068cm/sec 24 hours after Percutaneous Transluminal Coronary Angioplasty and 8.992cm/sec three months after Percutaneous Transluminal Coronary Angioplasty.

P value was less than 0.0001 when comparing 24 hours before and 24 hours after Percutaneous Transluminal Coronary Angioplasty. This is extremely significant.

Similarly p value for Sm velocity of basal septum was less than 0.0001

at 3 months post Percutaneous Transluminal Coronary Angioplasty which is significant.

Table 5

Em velocity of basal medial septum 24 hours before PTCA,24 hours after PTCA,3 months after PTCA

24hour before PTCA

24 hours after PTCA

3 months after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Em

5.141

0.679

0.070

5.09

0.684

0.071

5.0162

0.6968

0.072

Two tailed p value

P =0.0902

Not significant

P <0.0001

significant

95% CI

-0.008 to 0.109

0.0445 to 0.1036

SD means standard deviation; SEM means standard error of mean; CI denotes confidence interval.

The mean Em velocity 24 hours before and 24 hours after Percutaneous Transluminal Coronary Angioplasty was similar i.e.5.141 vs 5.09.when computing p value 24 hours after Percutaneous Transluminal Coronary Angioplasty the change in mean Em velocity was not statistically significant.

The mean Em velocity 3 months after Percutaneous Transluminal Coronary Angioplasty was 5.016cm/sec.Em velocity at 3 months does not change significantly after 3 months, even though the p value was less than 0.0001 significantly.

Table 6

Am velocity of basal medial septum 24 hours before PTCA, 24 hours after PTCA, 3 months after PTCA

24hour before PTCA

24 hours after PTCA

3 months after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Am

13.237

1.098

0.114

13.172

1.130

0.117

12.548

1.19

0.124

Two tailed p value

P= 0.0731

Not significant

P<0.0001

Significant

95% CI

-0.006 to 0.135

0.553 to 0.694

SD denotes standard deviation; SEM denotes standard error of mean

The mean Am tissue velocity 24 hours before Percutaneous Transluminal Coronary Angioplasty was 13.237cm/sec and 24 hours after Percutaneous Transluminal Coronary Angioplasty was 13.172 cm/sec with p value of equal to 0.0731.This is not statistically significant.

At 3 months post Percutaneous Transluminal Coronary Angioplasty, the mean Em velocity was 12.548 cm/sec with p value of less than 0.0001, is statistically significant.

Figure 2 trend of tissue Doppler imaging finding basal septum ventricle

Table 7

Sm velocity of basal lateral wall Left Ventricle 24 hours before PTCA, 24 hours after PTCA, 3 months after PTCA

24hour

before PTCA

24 hours

after PTCA

3 months

after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Sm

10.141

0.743

0.077

10.284

0.744

0.077

10.244

0.72

0.075

Two tailed p value

P<0.0001

Significant

P=0.0630

Not significant

95% CI

-0.189 to -0.097

-0.002 to 0.080

SD means standard deviation; SEM means standard error of mean

The basal Sm velocity 24 hours before Percutaneous Transluminal Coronary Angioplasty increased from 10.141cm/sec to 10.284cm/sec 24 hours after Percutaneous Transluminal Coronary Angioplasty and 10.244cm/sec 3 months post Percutaneous Transluminal Coronary Angioplasty.

The p value 24 hours after Percutaneous Transluminal Coronary Angioplasty was less than 0.0001 and is more significant. Three months post Percutaneous Transluminal Coronary Angioplasty, p value was equal to 0.0630 which is not significant statistically.

The change in Sm velocity 24 hours before; 24 hours after Percutaneous Transluminal Coronary Angioplasty and 3 months after Percutaneous Transluminal Coronary Angioplasty was similar.

Table 8

Em velocity of basal lateral wall of Left Ventricle 24 hours before PTCA, 24 hours after PTCA, 3 months after PTCA

24hour before PTCA

24 hours after PTCA

3 months after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Em

8.927

0.816

0.085

8.873

0.831

0.086

8.855

0.802

0.083

Two tailed p value

P= 0.0536

Not significant

P= 0.3879

Not significant

95% CI

-0.001 to 0.108

-0.024 to 0.080

SD denotes standard deviation; SEM denotes standard error of mean

Mean Early diastolic velocity Em changed from 8.927 cm/sec 24 hours before Percutaneous Transluminal Coronary Angioplasty to 8.873cm/sec 24 hours after Percutaneous Transluminal Coronary Angioplasty with p value =0.0536 which is not significant.

The mean early diastolic velocity Em changed from 8.873cm/sec 24 hours after Percutaneous Transluminal Coronary Angioplasty to 8.855cm/sec 3 months after Percutaneous Transluminal Coronary Angioplasty.

This p value was equal to 0.38 and is not significant.

Table 9

Am velocity of basal lateral wall of LV 24 hours before PTCA, 24 hours after PTCA, 3 months after PTCA

24hour before PTCA

24 hours after PTCA

3 months after PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

Am

14.637

0.997

0.103

14.570

0.959

0.099

14.511

0.97

0.101

Two tailed p value

P=0.0040

Significant

P=0.0004

Significant

95% CI

0.022 to 0.112

0.027 to 0.091

SD denotes standard deviation; SEM denotes standard error of mean

The peak late diastolic velocity Am changed from 14.637 cm/sec to 14.570 cm/sec 24 hours after Percutaneous Transluminal Coronary Angioplasty with p value=0.0040 which is significant. Am velocity 3 months post Percutaneous Transluminal Coronary Angioplasty was 14.511cm/sec with p value=0.0004 and was significant.

Figure 3 trends of tissue Doppler imaging values of lateral mitral annulus

Table 10

End Diastolic Dimension of Left Ventricle

24 hours before PTCA

24 hours after PTCA

3 months post PTCA

Variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

EDD

51.49

3.43

0.36

51.40

2.65

0.28

50.88

2.57

0.27

Two tailed p value

P=0.6017

Not significant

P=0.0064

Significant

95% CI

-0.27 to 0.46

0.15 to 0.88

SD means standard deviation; SEM denoted standard error of mean

End diastolic dimension 24 hours before Percutaneous Transluminal Coronary Angioplasty was 51.49 cm and 24 hours after Percutaneous Transluminal Coronary Angioplasty was 51.40 cm with p value = 0.6017 .There is no significant change in End diastolic dimension. End diastolic dimension decreased significantly after 3 months post Percutaneous Transluminal Coronary Angioplasty to 50.88 cms with non significant p value 0.0064.

Table 11

End Systolic Dimension of Left Ventricle

24 hours before PTCA

24 hours after PTCA

3 months post PTCA

variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

ESD

38.94

2.76

0.29

39.15

2.35

0.24

39.11

2.29

0.24

Two tailed

t test p value

P=0.2673

Not significant

P=0.8348

Significant

95% CI

-0.60 to 0.17

-0.37 to 0.45

SD denoted standard deviation; SEM denotes standard error of mean

End systolic dimension increased from 38.94 cm to 39.15 cm 24 hours post Percutaneous Transluminal Coronary Angioplasty with p value = 0.2673.This change in end systolic dimension was not significant.

Three months post Percutaneous Transluminal Coronary Angioplasty the end systolic dimension was 39.11 with p value=0.8348 and was significant with two tailed t test

Table 12

Change in 2D Ejection Fraction

24 hours before PTCA

24 hours after PTCA

3 months post PTCA

variables

Mean

SD

SEM

Mean

SD

SEM

Mean

SD

SEM

EF

48.834

1.836

0.190

49.79

2.426

0.252

49.095

2.295

0.238

Two tailed p value

P=0.0024

Significant

P=0.0285

Significant

95% CI

-1.564 to -0.348

0.075 to 1.317

SD denotes standard deviation; SEM denotes standard error of mean

Ejection Fraction 24 before Percutaneous Transluminal Coronary Angioplasty was 48.834 % and 24 hours post Percutaneous Transluminal Coronary Angioplasty was 49.79%.The p value was 0.0024 and was significant.

Ejection Fraction 3 months post Percutaneous Transluminal Coronary Angioplasty was 49.095% with p value of 0.0285 which was significant.

Figure 4 trends of End Diastolic Dimension, End Systolic Dimension and Ejection Fraction

Table 13

Changes in Em/Am ratio

Variables

Basal septal wall of LV

Basal lateral wall of LV

24 hrs before PTCA

24 hrs

after PTCA

3 months after

PTCA

24 hrs before PTCA

24 hrs after PTCA

3 months after

PTCA

Em

5.141

5.09

5.016

8.927

8.873

8.855

Am

13.237

13.172

12.548

14.637

14.570

14.51

Em/Am

0.388

0.386

0.399

0.609

0.608

0.610

LV denoted left ventricle

Em velocity of basal medial septum and basal lateral wall of left ventricle was similar 24 hours before,24 hours after and 3 months post Percutaneous Transluminal Coronary Angioplasty.

Similarly Am velocity of basal medial septum and basal lateral wall of left ventricle also does not change significantly 24 hours before, 24 hours after and 3 months after Percutaneous Transluminal Coronary Angioplasty.

There was no significant change in Em/Am ratio of both basal septum and basal lateral wall of left ventricle.

Trend of Em/Am ratio

DISCUSSION

DISCUSSION

Majority of patients in this study were males and only 8 females. There was selection bias and the sample volume was only 93 which is less.

Smoking is the most common risk factor in our study followed by diabetes mellitus.35 smokers also had diabetes mellitus as risk factor for coronary heart disease.

Peak systolic velocity(Sm) of basal septum of left ventricle increased significantly 24 hours after PTCA and 3 months after Percutaneous Transluminal Coronary Angioplasty. This increase in peak myocardial systolic velocity indicates there is a definite increase in left ventricle systolic function after percutaneous coronary angioplasty.

There is a phenomenal increase in peak myocardial systolic velocity of basal lateral wall of left ventricle 24 hours after coronary angioplasty, but there is no increase after 3 months.

This increase in peak systolic myocardial velocity indicates a very good recovery of myocardium after percutaneous transluminal coronary angioplasty.

Em velocity and Am velocity of basal medial septum does not increase significantly immediately after percutaneous coronary angioplasty with stenting. Hence the diastolic function of left ventricle takes some time to improve after angioplasty even though the systolic function on ventricles increase within a day.

Early diastolic and late diastolic velocity of basal medial annulus increased significantly after 3 months. So the diastolic function improvement takes more time, in our study.

The peak systolic myocardial velocity basal lateral wall changed upwards within a day after angioplasty, but very less change after 3 months. This may be due to the fact already there is good improvement in left ventricle systolic function.

Diastolic function of lateral basal wall of left ventricle does not increase even after 3 months. The reason for lack of improvement in diastolic function may be because lateral wall of left ventricle is not supplied by left anterior descending coronary artery and these patients do not have disease in left circumflex coronary artery.

End diastolic and end systolic dimension changed significantly after 3 months of angioplasty and ejection fraction also increased after few months.

As per prior studies, our study in Indian patients also showed the effect of ischemia on longitudinal function of left ventricle.

Based on our analysis regional contraction abnormality of ventricles could be derived with Doppler tissue imaging. More over the improvement in left ventricle systolic function is preserved after 3 months post coronary angioplasty.

Study limitations

Tissue Doppler imaging values was affected by pull and drag of adjacent myocardial segments leading to underestimation or overestimation. The exact place were sample volume was placed can change between examinations. The values obtained with tissue Doppler. This limitation can be removed by using strain and strain rate image technique.

Again strain rate imaging is not available in all institution. Myocardial velocity gradient was not measured which indicates viable myocardium. With speckle tracking there is no angle dependence during measurement.SPECT myocardial perfusion imaging is the gold standard to assess the reperfusion of ventricle, but again it is costly and not available in all centres.

CONCLUSION

CONCLUSION

Our prospective follow up study we showed that tissue Doppler myocardial imaging indices such as Sm, Em, Am will be helping us to decide the improvement in left ventricle function following angioplasty.

Our findings are similar to previous animal and human studies. In conclusion we can use tissue Doppler imaging as an easily available technique to assess the reperfusion and change in regional ventricle function.

PROFORMA

NAME: AGE: SEX: IP NO:

CHIEF COMPLAINTS:

PAST HISTORY:

RISK FACTORS:

GENERAL EXAMINATION:

PULSE RATE:

BLOOD PRESSURE:

CARDIOVASCULAR EXAMINATION:

RESPIRATORY SYSTEM:

ABDOMINAL EXAMINATION:

NERVOUS SYSTEM EXAMINATION:

INVESTIGATIONS:

RANDOM BLOOD SUGAR

BLOOD UREA

SERUM CREATININE:

ELECTROCARDIOGRAM:

CHEST RADIOGRAPH:

ECHOCARDIOGRAM:

PLAX

M MODE:

END DIASTOLIC DIMENSION

END SYSTOLIC DIMENSION

EJECTION FRACTION

TISSUE DOPPLER IMAGING

24 HOURS BEFORE PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

BASAL MEDIAL SEPTUM BASAL LATERAL WALL LV

Sm Em AM Sm Am Em

24 HOURS AFTER PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

BASAL MEDIAL SEPTUM BASAL LATERAL WALL LV

Sm Em Am Sm Em Am

3 MONTHS POST PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

BASAL MEDIAL SEPTUM BASAL LATERAL SEPTUM

Sm Em Am Sm Em Am