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Correlation Between Doppler Tissue
Findings and Coronary Lesion

Galache, José G.; Salazar, José;
Sánchez-Rubio, J. Juan; Cay, Eduardo;
Calvo, Isabel; Artal, Angel; Placer, Luis J.

Hospital Universitario Miguel Servet, Zaragoza, Spain

SUMMARY
Aims: Determine relationships between diastolic and systolic parameters of M-colour and tisular Doppler (DTI), and coronary lesion severity.
Material and Methods: 45 patients without ischemic cardiopathy history, following coronariography for coronary disease suspicion. DTI echocardiogram monitoring (wave E speed, systolic peak and E/A ratio) in anterior, inferior, septal and lateral walls in apical access of 2 and 4 chambers at 1 cm from mitral annulus. We related data obtained with major estenosis occurrence >60%, risk factors and treatment.
Results: 20 patients presented coronary lesions (> 60%), and 25 did not. No significant differences were found among groups regarding pharmacological therapy, ventricular hypertrophy and risk factors, neither in M-colour measures. In descendent anterior estenosis (LAD >60%), mean wave E speed (cm/s) was 6.9 in septum, 7.3 in anterior wall, 8.7 in lateral, and 7.7 in inferior. In LAD estenosis <60%, wave E mean speed was 9 in septum, 9.4 in anterior wall, 10.2 in lateral, and 9.4 in inferior, p<0.05. Systolic wave speed in anterior wall was minor in estenosis (6.7 vs 8.3 cm/s). No differences in DTI parameters were found in case of circumflex (CX) or right coronary (RCA) estenosis.
Conclusions: No relationship between M-color Doppler and coronary lesion occurrence was found. DTI parameters are linked to coronary disease in estenosis patients >60% in LAD (wave E mean speed in all walls and systolic peak in anterior wall are significantly minor). In CX estenosis >60% and RCA no significant differences in DTI parameters occur.

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INTRODUCTION
   The diastolic function in the ischemic cascade is affected before systolic function, before changes in the electrocardiogram occur, and before angor pectoris appears. For this reason, the study of diastole can be of great interest, particularly if the regional diastolic function could be studied.

   Doppler tissue (DTI) is a new technique that provides wider information on diastolic function than other well-established techniques, thus allowing diagnosis of more complex patterns. Even myocardial areas with different diastolic function can be identified. DTI is based on detecting mobility of myocardial walls by a pulsed Doppler recording. The sensor is located in the myocardium of the ventricular wall and its movements corresponding to the different phases of the cardiac cycle are monitored.

   The sensor of the pulsed Doppler is placed either on the longitudinal parasternal plane of the posterior wall or at 1 cm from the mitral ring in the 2 and 4 chambers view. A recording of the two phases of the cardiac cycle is thus obtained, as by conventional Doppler, but selective for each of the cardiac walls. The flow curves are of less speed than in conventional Doppler, but in agreement with them: systolic, E and A waves.

   In order to discriminate between the different diastolic patterns, the maximum speed (or peak speed) of each wave in measured instead of the time-measurements of conventional Doppler. Changes in speed and other parameters of DTI as a function of age, arterial hypertension (AHT), left ventricular hypertrophy (LVH) and pharmaceutical therapy can be found.

OBJECTIVES
   The aims of this study were as follows:
- To check the presence or absence of a good correlation between the findings by Doppler tissue and the existence or not of coronary lesions.
- To demonstrate the significant alteration of the Doppler pattern in the presence of coronary lesions as compared with patients without this type of lesion.

MATERIALS AND METHODS
   A prospective and random study was developed. Transthoracic echocardiograms (TTE) were made to 45 in rest patients without known ischemic cardiopathy, who then were subjected to coronography due to coronary illness suspicion. The TTE was performed under hemodynamic stability. The usual parameters of the diastolic function were recorded by the TTE, namely: ejection and shortening fractions, cavity diameters, isovolumetric relaxation time (IVRT), deceleration time for wave E and E/A wave ratio, presence of mitral insufficiency, hypertrophy degree and mitral filling pattern with color-M mode. In addition, the wave-E speed, slope of the deceleration of wave E, systolic peak and E/A wave ratio in the anterior, inferior, septum and lateral walls in the apical access of 2 and 4 chambers at 1 cm from the mitral ring were obtained. An ATL 5000 echocardiograph was used for obtaining the echocardiograms.

   After performing the coronariography the target patients were divided into two groups: one including those with angiographic lesions higher than 60%, and other with patients both without lesions and with lesions lower than 60%. Three subgroups were also established depending on the coronary type: anterior descendent, circumflex and right coronary. The results of the echography from these groups were compared.

   Due to the reduced number of samples (patients) the statistical method used for data treatment was the non-parametric Mann-Whitney U test.

RESULTS
   Between the 45 patients of the overall sample, 20 of them had coronary lesions with stenosis higher than 60%. In fact the average stenosis of this group was higher than 78%; aspect that must be taken into account in assessing the data.

   As can be seen in Table 1, no significant differences between both groups (with and without coronary lesions higher than 60%) were found concerning sex, age and risk factors. Neither the pharmaceutical therapy of the patients enabled to establish significant differences between groups (see Table 2).


   Concerning Doppler in colour-M mode, a slope of the speed of wave E of 61 cm/s was obtained for the group of coronary lesions lower than 60%. For lesions higher than 60% of stenosis the slope of the speed of wave E was 58 cm/s. Therefore, the difference between both groups was very small and, so non significant.

   The results obtained from Doppler tissue are summarized in Tables 3 and 4, where only the speeds of the systolic and E waves are included and the three coronary territories are separated depending on the vessel affected.

   The group of patients with lesions higher than 60% in the anterior descendent yielded average of wave E speed in the four described points where the data were acquired (septum and anterior, lateral and inferior walls) lower than that of the group with low coronary lesions, with significant differences for p<0.05.

   The differences in the speed of the systolic wave yielded significant values (p<0.05) between both groups only in the case of DTI sensor placed in the anterior wall, but not for other walls.

    The differences between groups were not significant (for neither of the parameters nor sensor position) from measurements with DTI when the affected vessel was the circumflex or right coronary.

DISCUSSION
   In the light of the results found, an acceptable correlation between the speeds measured by DTI in the case of wave E for the four target points (namely, septum and anterior, lateral and inferior walls) can be inferred when the lesion is located in the anterior descendent. The average speed in the presence of lesion is lower than 8.5 cm/s in all instances; datum in agreement with related literature. The same happens in the case of the systolic wave, but the difference is significant only for the case of sensor in the anterior wall. When the lesions are in other territory there are not significant differences in the measurements obtained by DTI.

   From the above, the usefulness of both wave E and systolic waves for discriminating lesions in the anterior descendent can be deduced. The results obtained could be influenced either by the myocardial mass or the size of the affected territory.

   On the other hand, and taking into account both the average stenosis of the group with lesions higher than 78% and that the echography is performed in rest, with no ischemia provocation, an important contribution from DTI in the non-invasive diagnosis of ischemic cardiopathy can be foreseeable. There is not necessity for ischemia provocation in this case, particularly taking into account that this type of stenosis lesions, higher than 80%, produces alterations of the regional diastole.

CONCLUSIONS
   The study hereby commented was devoted to two very homogenous groups concerning risk factors, age and pharmaceutical treatment. No relationship between measurements in color-M mode, Doppler and the existence of coronary lesions has been found. The findings of TDI in the case of lesions higher than 60% in the anterior descendent (speed of wave E in all walls and the systolic wave only in the anterior wall) are very useful for identifying these lesions. The speed of the waves is always lower in the case of coronary lesion. When the lesions appear in other territory different from the anterior descendent, there are not differences in the DTI findings.

    Nevertheless, more in depth studies with a bigger number of patients are mandatory in order to assess these findings.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
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