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      Diastolic Filling Patterns and the Valsalva Maneuver

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      Cardiology
      S. Karger AG

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          Role of left ventricular stiffness in heart failure with normal ejection fraction.

          Increased left ventricular stiffness is a distinct finding in patients who have heart failure with normal ejection fraction (HFNEF). To elucidate how diastolic dysfunction contributes to heart failure symptomatology during exercise, we conducted a study using an invasive pressure-volume loop approach and measured cardiac function at rest and during atrial pacing and handgrip exercise. Patients with HFNEF (n=70) and patients without heart failure symptoms (n=20) were enrolled. Pressure-volume loops were measured with a conductance catheter during basal conditions, handgrip exercise, and atrial pacing with 120 bpm to analyze diastolic and systolic left ventricular function. During transient preload reduction, the diastolic stiffness constant was measured directly. Diastolic function with increased stiffness was significantly impaired in patients with HFNEF during basal conditions. This was associated with increased end-diastolic pressures during handgrip exercise and with decreased stroke volume and a leftward shift of pressure-volume loops during atrial pacing. Increased left ventricular stiffness contributed to increased end-diastolic pressure during handgrip exercise and decreased stroke volume during atrial pacing in patients with HFNEF. These data suggest that left ventricular stiffness modulates cardiac function in HFNEF patients and suggests that diastolic dysfunction with increased stiffness is a target for treating HFNEF.
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            The pulmonary venous systolic flow pulse--its origin and relationship to left atrial pressure.

            The purpose of this study was to determine the origin of the pulmonary venous systolic flow pulse using wave-intensity analysis to separate forward- and backward-going waves.
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              Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study.

              The aim of this study was to demonstrate the usefulness of preload alterations in assessing left ventricular filling pressures with transmitral Doppler velocity curves. Doppler mitral inflow velocities, used to estimate left ventricular filling pressures noninvasively, are limited in predicting left ventricular filling pressures, especially in patients with normal systolic function and a "pseudonormal" mitral filling pattern. Forty-nine patients were studied in the cardiac catheterization laboratory with simultaneous Doppler echocardiography using high fidelity catheters to compare left ventricular diastolic filling pressures (pre-A wave left ventricular pressure) and Doppler mitral inflow at baseline and during reduction of preload during the strain phase of the Valsalva maneuver (n = 27) or sublingual nitroglycerin (n = 36), or both (n = 14). Doppler measurements consisted of E (initial peak velocity), A (velocity at atrial contraction), deceleration time (time from E velocity to deceleration of flow extrapolated to baseline) and absolute A wave velocity (A' [peak A wave velocity minus velocity at onset of atrial contraction]). In patients with high pre-A wave pressure (> or 15 mm Hg), there was a greater change in the E/A' ratio during the Valsalva maneuver than in patients with a normal pre-A wave pressure (-1.22 +/- 1.1 vs. -0.35 +/- 0.17; p = 0.02). A similar change was seen when comparing the change in the E/A' ratio after administration of nitroglycerin in patients with a high versus a normal pre-A wave pressure (0.81 +/- 0.49 vs. 0.18 +/- 0.17; p < 0.001). These differences were present in patients with a normal E/A ratio at baseline. Alterations in preload during assessment of Doppler echocardiographic indexes may be useful in noninvasively assessing left ventricular filling pressures.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2014
                July 2014
                19 June 2014
                : 128
                : 4
                : 352-354
                Affiliations
                Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Fla., USA
                Author notes
                *Steven J. Lavine, MD, Division of Cardiology, Internal Medicine, East Tennessee State University, 329 North State of Franklin Road, Johnson City, TN 37604 (USA), E-Mail stevenjlavine@gmail.com
                Article
                360934 Cardiology 2014;128:352-354
                10.1159/000360934
                24970381
                a5786695-4d0e-4aa0-a946-a41620f4dc6e
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 27 February 2014
                : 27 February 2014
                Page count
                Pages: 3
                Categories
                Editorial Comment

                General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology
                General medicine, Neurology, Cardiovascular Medicine, Internal medicine, Nephrology

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