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Detection of Left Ventricular Dysfunction With Tei Index in Normal Ejection Fraction Patients With Mitral Regurgitation Before Mitral Valve Surgery
Detection of Left Ventricular Dysfunction With Tei Index in Normal Ejection Fraction Patients With Mitral Regurgitation Before Mitral Valve Surgery Kunitsugu Takasaki, MDa, A. Marc Gillinov, MDb, Tetsuhiro Yamano, MDa, Yoshiki Matsumura, MDa, Manotomo Toyono, MDa, and Takahiro Shiota, MDc,* Ejection fraction (EF) was not considered a reliable parameter of left ventricular (LV) function and was normal in most patients with chronic mitral regurgitation (MR), whereas LV dysfunction expressed as decreased EF was often shown after mitral valve surgery. This study sought the ability of the Tei index to detect latent LV dysfunction in patients with MR and apparently normal EF. One hundred eight patients with apparently normal EF (EF >50%) and chronic severe MR who underwent mitral valve repair were investigated. EF was significantly decreased after surgery and LV dysfunction (EF <50%) was shown in 37 patients (34% of all patients). The preoperative Tei index significantly correlated with postoperative EF in all patients (r ⴝ ⴚ0.64, p <0.0001) and asymptomatic patients (n ⴝ 44; r ⴝ ⴚ0.57, p <0.0001). By setting the preoperative Tei index >0.5 to predict postoperative EF <50%, this index had sensitivity, specificity, and accuracy of 89%, 85%, and 86% in all patients and 80%, 85%, and 84% in asymptomatic patients, respectively. In conclusion, a preoperative Tei index >0.5 allowed prediction of postoperative LV dysfunction in patients with MR with apparently normal EF. Thus, earlier surgery is recommended in asymptomatic patients with MR with normal EF, but Tei index >0.5. © 2009 Elsevier Inc. (Am J Cardiol 2009;103:1011–1014)
Chronic mitral regurgitation (MR) causes progressive left ventricular (LV) dysfunction.1–3 LV systolic dysfunction has a deleterious impact on postoperative outcome and LV function. Therefore, determination of the optimal timing of surgical intervention is important.4 However, ejection fraction (EF), which was most commonly used as an LV functional parameter, had not proved reliable in the presence of severe MR.5–7 EF appeared to remain normal in most patients with chronic MR, whereas LV dysfunction, expressed as decreased EF, was often shown after mitral valve surgery. We hypothesized that the Tei index,8 derived from simple time analysis and expressing global LV function, has the potential to detect LV myocardial dysfunction even in patients with apparently normal EF with severe MR. The purpose of this study was to investigate and compare relations between preoperative indexes of cardiac function, including the Tei index, and postoperative EF in patients with chronic severe MR. Methods and Results We performed retrospective studies in 108 consecutive patients (72 men, 36 women; mean age 56 ⫾ 12 years) with apparently normal EF (EF ⱖ50%) and chronic severe MR Departments of aCardiovascular Medicine and bCardiac Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; and cCedars-Sinai Medical Center and University of California, Los Angeles, California. Manuscript received August 19, 2008; revised manuscript received and accepted November 21, 2008. *Corresponding author: Tel: 216-445-7287; Fax: 216-445-7306. E-mail address: [email protected] (T. Shiota). 0002-9149/09/$ – see front matter © 2009 Elsevier Inc. doi:10.1016/j.amjcard.2008.11.056
who underwent uncomplicated mitral valve repair and annuloplasty for mitral valve prolapse and flail. The Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, California) was used in all patients. The likelihood of successful mitral valve repair was achieved in 99% of patients with posterior leaflet prolapse/flail and 95% of patients with anterior leaflet prolapse/flail in Cleveland Clinic. Patients with concomitant coronary artery disease, previous cardiac surgery, other moderate or severe valvular diseases, and atrial fibrillation were excluded. Standard 2-dimensional and Doppler echocardiography was performed before (average 19 ⫾ 27 days) and after surgery (average 4 ⫾ 3 days). EF was determined using the modified biplane Simpson’s method. Pulsed Doppler profiles of mitral inflow and LV outflow were obtained successively from the apical view, and heart rate was unchanged during the pulsed Doppler recording. The Tei index was calculated as previously reported (Figure 1).8 Interval “a” from cessation to the onset of mitral inflow and interval “b” from the duration of aortic flow, which is ejection time, were measured. The Tei index was calculated as (a ⫺ b)/b. We also measured interval “c” between peak QRS and the onset of mitral inflow and interval “d” between peak QRS and cessation of LV ejection flow. Therefore, isovolumic relaxation time ⫽ c ⫺ d, and isovolumic contraction time ⫽ (a ⫺ b) ⫺ (c ⫺ d).8 Data were obtained from ⬎3 consecutive cardiac cycles and averaged. Two independent observers repeated 10 measurements of the Tei index. Variability in the differences in measurements by the 2 observers was obtained to express interobserver variability. The same observer repeated 10 measurements, and intraobserver variability was also calculated. www.AJConline.org
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The American Journal of Cardiology (www.AJConline.org)
Figure 2. Receiver-operator characteristic curves for predicting postoperative LV dysfunction.
Table 3 Correlation (r) of Tei index and its components with postoperative ejection fraction in symptomatic and asymptomatic patients Variable Figure 1. Measurements of the Tei index, isovolumic contraction time (ICT), and isovolumic relaxation time (IRT). ECG ⫽ electrocardiography; ET ⫽ ejection time. Table 1 Pre- and postoperative echocardiographic data Variable Left atrial diameter (mm) LV diastolic dimension (mm) LV systolic dimension (mm) LV end-diastolic volume (ml) LV end-systolic volume (ml) LVEF (%)
Preoperative
Postoperative
p Value
46 ⫾ 7 57 ⫾ 7 35 ⫾ 6 170 ⫾ 44 55 ⫾ 19 68 ⫾ 7
42 ⫾ 6 50 ⫾ 6 36 ⫾ 7 120 ⫾ 34 58 ⫾ 26 53 ⫾ 11
⬍0.0001 ⬍0.0001 ⬍0.01 ⬍0.0001 ⬍0.05 ⬍0.0001
Table 2 Correlation between preoperative parameters and postoperative ejection fraction (EF) Independent Variable
Left atrial diameter (mm) LV end-diastolic volume (ml) LV end-systolic volume (ml) LVEF (%) Tei index
Univariate Analysis
Multiple Stepwise Regression Analysis
r
p Value
Standard Regression Coefficient
p Value
⫺0.58 ⫺0.52
⬍0.0001 ⬍0.0001
⫺0.22
0.0065
⫺0.64
⬍0.0001
⫺0.31
0.0003
0.50 ⫺0.64
⬍0.0001 ⬍0.0001
⫺0.41
⬍0.0001
Results were expressed as mean ⫾ SD. Correlation between continuous variables was analyzed using simple linear regression analysis. Multiple stepwise linear regression analysis was performed to determine independent predictors of postoperative EF. Receiver-operator characteristic curve analysis was performed to test the diagnostic power of each
All Patients (n ⫽ 108)
Symptomatic Patients (n ⫽ 64)
Asymptomatic Patients (n ⫽ 44)
⫺0.64* 0.54* ⫺0.68*
⫺0.67* 0.57* ⫺0.72*
⫺0.57* 0.50† ⫺0.59*
⫺0.03
⫺0.06
⫺0.03
Tei index Ejection time (ms) Isovolumic contraction time (ms) Isovolumic relaxation time (ms) * p ⬍0.0001; † p ⬍0.001.
parameter and determine the best cut-off value to identify postoperative LV dysfunction. Pre- and postoperative echocardiographic data are listed in Table 1. Left atrial diameter, LV end-diastolic diameter, LV end-diastolic volume, and EF were significantly decreased after mitral valve surgery. The Tei index did not significantly change after surgery (0.50 ⫾ 0.14 to 0.49 ⫾ 0.12; p ⫽ NS). LV end-systolic diameter and volume were significantly, but modestly, increased after surgery. LV dysfunction (EF ⬍50%) was shown after surgery in 37 patients (34% of all patients). The preoperative regurgitant fraction was 59 ⫾ 12%, and 13 patients had residual MR (10 patients with trace and 3 patients with mild) early after mitral valve surgery in all patients. All preoperative parameters significantly correlated with postoperative EF (Table 2). The most powerful predictors were the Tei index (r ⫽ ⫺0.64, p ⬍0.0001) and LV endsystolic volume (r ⫽ ⫺0.64, p ⬍0.0001). However, multivariate analysis showed that the Tei index, LV end-systolic volume, and left atrial diameter were independent predictors of postoperative EF. Of these parameters, the Tei index had the most significant correlation with postoperative EF (p ⬍0.0001). Areas under the curves in receiver-operator characteristic curve analyses for identifying postoperative LV dysfunction (EF ⬍50%) using the Tei index, LV end-systolic volume, and left atrial diameter were 0.93, 0.82, and 0.73, respectively (Figure 2). Sensitivity, specificity, and accuracy in
Valvular Heart Disease/Tei Index in Mitral Regurgitation
1013
Figure 3. Tei index and its components versus postoperative EF.
predicting postoperative LV dysfunction with a preoperative Tei index ⬎0.5 were 89%, 85%, and 86%. Correlations of the Tei index and its components with postoperative EF are shown in Table 3 and Figure 3. We divided patients into the 2 groups of symptomatic (n ⫽ 64) and asymptomatic (n ⫽ 44) to confirm the utility of the Tei index in each group. The Tei index had a significant correlation with postoperative EF in asymptomatic and symptomatic patients. A preoperative Tei index ⬎0.5 also had good diagnostic accuracy for postoperative LV dysfunction in asymptomatic patients (sensitivity, specificity, and accuracy of 80%, 85%, and 84%) and symptomatic patients (sensitivity, specificity, and accuracy of 93%, 84%, and 88%). Ejection time and isovolumic contraction time significantly correlated with postoperative EF in all patients, asymptomatic patients, and symptomatic patients. Isovolumic relaxation time did not significantly correlate with postoperative EF in either group. Inter- and intraobserver variabilities for measurement of the Tei index were 0.03 ⫾ 0.02% or 5.9 ⫾ 5.0% of the mean value and 0.01 ⫾ 0.01% or 2.9 ⫾ 2.7%, respectively. Discussion This study showed good correlation between the preoperative Tei index and postoperative EF. Although several preoperative parameters of LV function have been used to predict LV function after surgery, these parameters were often time consuming and invasive to measure.7,9 –15 Advantages of the Tei index over other echocardiographic parameters were relatively volume independent and simple measurement with lower interobserver variability.8,16 Additional time analysis showed that isovolumic contraction time had the most significant correlation with postoperative EF. Pai et al17 supported our results, indirectly describing the good correlation between positive dP/dt, which was approximately parallel to isovolumic contraction time, and postoperative EF in patients with MR.
Although most patients with MR may have good outcomes after surgery in accordance with the current guidelines,3 management of asymptomatic patients with MR is still controversial.18,19 Patients with MR may remain asymptomatic for many years,20 and LV dysfunction may progress without apparently decreasing EF. In 30 asymptomatic patients who did not meet the criteria of the guidelines, 3 patients (10%) showed LV dysfunction after surgery. Two of these 3 patients had a Tei index ⬎0.5. In 14 asymptomatic patients who met the criteria, 7 patients (50%) showed LV dysfunction, whereas 8 of 13 asymptomatic patients (62%) with a Tei index ⬎0.5 showed LV dysfunction after surgery. Al-Mukhaini et al21 reported that the Tei index was also useful to predict adverse outcomes after mitral valve surgery, although no investigation was made of postoperative EF or LV function. Therefore, the Tei index may be of great clinical value for surgical decision making in asymptomatic patients with normal EF and severe MR. 1. Corin WJ, Sutsch G, Murakami T, Krogmann ON, Turina M, Hess OM. Left ventricular function in chronic mitral regurgitation: preoperative and postoperative comparison. J Am Coll Cardiol 1995;25: 113–121. 2. Carabello BA. The pathophysiology of mitral regurgitation. J Heart Valve Dis 2000;9:600 – 608. 3. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, et al. ACC/ AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84 – e231. 4. Ross J Jr. Left ventricular function and the timing of surgical treatment in valvular heart disease. Ann Intern Med 1981;94:498 –504. 5. Eckberg DL, Gault JH, Bouchard RL, Karliner JS, Ross J Jr. Mechanics of left ventricular contraction in chronic severe mitral regurgitation. Circulation 1973;47:1252–1259.
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6. Starling MR, Kirsh MM, Montgomery DG, Gross MD. Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction. J Am Coll Cardiol 1993; 22:239 –250. 7. Crawford MH, Souchek J, Oprian CA, Miller DC, Rahimtoola S, Giacomini JC, Sethi G, Hammermeister KE. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation 1990;81:1173–1181. 8. Tei C, Ling LH, Hodge DO, Bailey KR, Oh JK, Rodeheffer RJ, Tajik AJ, Seward JB. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function—a study in normals and dilated cardiomyopathy. J Cardiol 1995;26:357–366. 9. Borow KM, Green LH, Mann T, Sloss LJ, Braunwald E, Collins JJ, Cohn L, Grossman W. End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med 1980;68:655– 663. 10. Carabello BA, Nolan SP, McGuire LB. Assessment of preoperative left ventricular function in patients with mitral regurgitation: value of the end-systolic wall stress-end-systolic volume ratio. Circulation 1981;64:1212–1217. 11. Zile MR, Gaasch WH, Carroll JD, Levine HJ. Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol 1984;3: 235–242. 12. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, Frye RL. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol 1994;24:1536 –1543. 13. Leung DY, Griffin BP, Stewart WJ, Cosgrove DM III, Thomas JD, Marwick TH. Left ventricular function after valve repair for chronic
14.
15.
16. 17. 18.
19.
20. 21.
mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996;28:1198 –1205. Lee R, Hanekom L, Marwick TH, Leano R, Wahi S. Prediction of subclinical left ventricular dysfunction with strain rate imaging in patients with asymptomatic severe mitral regurgitation. Am J Cardiol 2004;94:1333–1337. Kim YJ, Jones M, Greenberg NL, Popovic ZB, Sitges M, Bauer F, Thomas JD, Shiota T. Evaluation of left ventricular contractile function using noninvasively determined single-beat end-systolic elastance in mitral regurgitation: experimental validation and clinical application. J Am Soc Echocardiogr 2007;20:1086 –1092. Moller JE, Poulsen SH, Egstrup K. Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance. J Am Soc Echocardiogr 1999;12:1065–1072. Pai RG, Bansal RC, Shah PM. Doppler-derived rate of left ventricular pressure rise. Its correlation with the postoperative left ventricular function in mitral regurgitation. Circulation 1990;82:514 –520. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, Scott C, Schaff HV, Tajik AJ. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875– 883. Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, Schemper M, Maurer G, Baumgartner H. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006;113:2238 – 2244. Delahaye JP, Gare JP, Viguier E, Delahaye F, De Gevigney G, Milon H. Natural history of severe mitral regurgitation. Eur Heart J 1991; 12(suppl B):S5–S9. Al-Mukhaini M, Argentin S, Morin JF, Benny C, Cusson D, Huynh T. Myocardial performance index as predictor of adverse outcomes following mitral valve surgery. Eur J Echocardiogr 2003;4:128 –134.
Chronic mitral regurgitation (MR) causes progressive left ventricular (LV) dysfunction.1–3 LV systolic dysfunction has a deleterious impact on postoperative outcome and LV function. Therefore, determination of the optimal timing of surgical intervention is important.4 However, ejection fraction (EF), which was most commonly used as an LV functional parameter, had not proved reliable in the presence of severe MR.5–7 EF appeared to remain normal in most patients with chronic MR, whereas LV dysfunction, expressed as decreased EF, was often shown after mitral valve surgery. We hypothesized that the Tei index,8 derived from simple time analysis and expressing global LV function, has the potential to detect LV myocardial dysfunction even in patients with apparently normal EF with severe MR. The purpose of this study was to investigate and compare relations between preoperative indexes of cardiac function, including the Tei index, and postoperative EF in patients with chronic severe MR. Methods and Results We performed retrospective studies in 108 consecutive patients (72 men, 36 women; mean age 56 ⫾ 12 years) with apparently normal EF (EF ⱖ50%) and chronic severe MR Departments of aCardiovascular Medicine and bCardiac Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; and cCedars-Sinai Medical Center and University of California, Los Angeles, California. Manuscript received August 19, 2008; revised manuscript received and accepted November 21, 2008. *Corresponding author: Tel: 216-445-7287; Fax: 216-445-7306. E-mail address: [email protected] (T. Shiota). 0002-9149/09/$ – see front matter © 2009 Elsevier Inc. doi:10.1016/j.amjcard.2008.11.056
who underwent uncomplicated mitral valve repair and annuloplasty for mitral valve prolapse and flail. The Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, California) was used in all patients. The likelihood of successful mitral valve repair was achieved in 99% of patients with posterior leaflet prolapse/flail and 95% of patients with anterior leaflet prolapse/flail in Cleveland Clinic. Patients with concomitant coronary artery disease, previous cardiac surgery, other moderate or severe valvular diseases, and atrial fibrillation were excluded. Standard 2-dimensional and Doppler echocardiography was performed before (average 19 ⫾ 27 days) and after surgery (average 4 ⫾ 3 days). EF was determined using the modified biplane Simpson’s method. Pulsed Doppler profiles of mitral inflow and LV outflow were obtained successively from the apical view, and heart rate was unchanged during the pulsed Doppler recording. The Tei index was calculated as previously reported (Figure 1).8 Interval “a” from cessation to the onset of mitral inflow and interval “b” from the duration of aortic flow, which is ejection time, were measured. The Tei index was calculated as (a ⫺ b)/b. We also measured interval “c” between peak QRS and the onset of mitral inflow and interval “d” between peak QRS and cessation of LV ejection flow. Therefore, isovolumic relaxation time ⫽ c ⫺ d, and isovolumic contraction time ⫽ (a ⫺ b) ⫺ (c ⫺ d).8 Data were obtained from ⬎3 consecutive cardiac cycles and averaged. Two independent observers repeated 10 measurements of the Tei index. Variability in the differences in measurements by the 2 observers was obtained to express interobserver variability. The same observer repeated 10 measurements, and intraobserver variability was also calculated. www.AJConline.org
1012
The American Journal of Cardiology (www.AJConline.org)
Figure 2. Receiver-operator characteristic curves for predicting postoperative LV dysfunction.
Table 3 Correlation (r) of Tei index and its components with postoperative ejection fraction in symptomatic and asymptomatic patients Variable Figure 1. Measurements of the Tei index, isovolumic contraction time (ICT), and isovolumic relaxation time (IRT). ECG ⫽ electrocardiography; ET ⫽ ejection time. Table 1 Pre- and postoperative echocardiographic data Variable Left atrial diameter (mm) LV diastolic dimension (mm) LV systolic dimension (mm) LV end-diastolic volume (ml) LV end-systolic volume (ml) LVEF (%)
Preoperative
Postoperative
p Value
46 ⫾ 7 57 ⫾ 7 35 ⫾ 6 170 ⫾ 44 55 ⫾ 19 68 ⫾ 7
42 ⫾ 6 50 ⫾ 6 36 ⫾ 7 120 ⫾ 34 58 ⫾ 26 53 ⫾ 11
⬍0.0001 ⬍0.0001 ⬍0.01 ⬍0.0001 ⬍0.05 ⬍0.0001
Table 2 Correlation between preoperative parameters and postoperative ejection fraction (EF) Independent Variable
Left atrial diameter (mm) LV end-diastolic volume (ml) LV end-systolic volume (ml) LVEF (%) Tei index
Univariate Analysis
Multiple Stepwise Regression Analysis
r
p Value
Standard Regression Coefficient
p Value
⫺0.58 ⫺0.52
⬍0.0001 ⬍0.0001
⫺0.22
0.0065
⫺0.64
⬍0.0001
⫺0.31
0.0003
0.50 ⫺0.64
⬍0.0001 ⬍0.0001
⫺0.41
⬍0.0001
Results were expressed as mean ⫾ SD. Correlation between continuous variables was analyzed using simple linear regression analysis. Multiple stepwise linear regression analysis was performed to determine independent predictors of postoperative EF. Receiver-operator characteristic curve analysis was performed to test the diagnostic power of each
All Patients (n ⫽ 108)
Symptomatic Patients (n ⫽ 64)
Asymptomatic Patients (n ⫽ 44)
⫺0.64* 0.54* ⫺0.68*
⫺0.67* 0.57* ⫺0.72*
⫺0.57* 0.50† ⫺0.59*
⫺0.03
⫺0.06
⫺0.03
Tei index Ejection time (ms) Isovolumic contraction time (ms) Isovolumic relaxation time (ms) * p ⬍0.0001; † p ⬍0.001.
parameter and determine the best cut-off value to identify postoperative LV dysfunction. Pre- and postoperative echocardiographic data are listed in Table 1. Left atrial diameter, LV end-diastolic diameter, LV end-diastolic volume, and EF were significantly decreased after mitral valve surgery. The Tei index did not significantly change after surgery (0.50 ⫾ 0.14 to 0.49 ⫾ 0.12; p ⫽ NS). LV end-systolic diameter and volume were significantly, but modestly, increased after surgery. LV dysfunction (EF ⬍50%) was shown after surgery in 37 patients (34% of all patients). The preoperative regurgitant fraction was 59 ⫾ 12%, and 13 patients had residual MR (10 patients with trace and 3 patients with mild) early after mitral valve surgery in all patients. All preoperative parameters significantly correlated with postoperative EF (Table 2). The most powerful predictors were the Tei index (r ⫽ ⫺0.64, p ⬍0.0001) and LV endsystolic volume (r ⫽ ⫺0.64, p ⬍0.0001). However, multivariate analysis showed that the Tei index, LV end-systolic volume, and left atrial diameter were independent predictors of postoperative EF. Of these parameters, the Tei index had the most significant correlation with postoperative EF (p ⬍0.0001). Areas under the curves in receiver-operator characteristic curve analyses for identifying postoperative LV dysfunction (EF ⬍50%) using the Tei index, LV end-systolic volume, and left atrial diameter were 0.93, 0.82, and 0.73, respectively (Figure 2). Sensitivity, specificity, and accuracy in
Valvular Heart Disease/Tei Index in Mitral Regurgitation
1013
Figure 3. Tei index and its components versus postoperative EF.
predicting postoperative LV dysfunction with a preoperative Tei index ⬎0.5 were 89%, 85%, and 86%. Correlations of the Tei index and its components with postoperative EF are shown in Table 3 and Figure 3. We divided patients into the 2 groups of symptomatic (n ⫽ 64) and asymptomatic (n ⫽ 44) to confirm the utility of the Tei index in each group. The Tei index had a significant correlation with postoperative EF in asymptomatic and symptomatic patients. A preoperative Tei index ⬎0.5 also had good diagnostic accuracy for postoperative LV dysfunction in asymptomatic patients (sensitivity, specificity, and accuracy of 80%, 85%, and 84%) and symptomatic patients (sensitivity, specificity, and accuracy of 93%, 84%, and 88%). Ejection time and isovolumic contraction time significantly correlated with postoperative EF in all patients, asymptomatic patients, and symptomatic patients. Isovolumic relaxation time did not significantly correlate with postoperative EF in either group. Inter- and intraobserver variabilities for measurement of the Tei index were 0.03 ⫾ 0.02% or 5.9 ⫾ 5.0% of the mean value and 0.01 ⫾ 0.01% or 2.9 ⫾ 2.7%, respectively. Discussion This study showed good correlation between the preoperative Tei index and postoperative EF. Although several preoperative parameters of LV function have been used to predict LV function after surgery, these parameters were often time consuming and invasive to measure.7,9 –15 Advantages of the Tei index over other echocardiographic parameters were relatively volume independent and simple measurement with lower interobserver variability.8,16 Additional time analysis showed that isovolumic contraction time had the most significant correlation with postoperative EF. Pai et al17 supported our results, indirectly describing the good correlation between positive dP/dt, which was approximately parallel to isovolumic contraction time, and postoperative EF in patients with MR.
Although most patients with MR may have good outcomes after surgery in accordance with the current guidelines,3 management of asymptomatic patients with MR is still controversial.18,19 Patients with MR may remain asymptomatic for many years,20 and LV dysfunction may progress without apparently decreasing EF. In 30 asymptomatic patients who did not meet the criteria of the guidelines, 3 patients (10%) showed LV dysfunction after surgery. Two of these 3 patients had a Tei index ⬎0.5. In 14 asymptomatic patients who met the criteria, 7 patients (50%) showed LV dysfunction, whereas 8 of 13 asymptomatic patients (62%) with a Tei index ⬎0.5 showed LV dysfunction after surgery. Al-Mukhaini et al21 reported that the Tei index was also useful to predict adverse outcomes after mitral valve surgery, although no investigation was made of postoperative EF or LV function. Therefore, the Tei index may be of great clinical value for surgical decision making in asymptomatic patients with normal EF and severe MR. 1. Corin WJ, Sutsch G, Murakami T, Krogmann ON, Turina M, Hess OM. Left ventricular function in chronic mitral regurgitation: preoperative and postoperative comparison. J Am Coll Cardiol 1995;25: 113–121. 2. Carabello BA. The pathophysiology of mitral regurgitation. J Heart Valve Dis 2000;9:600 – 608. 3. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, et al. ACC/ AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84 – e231. 4. Ross J Jr. Left ventricular function and the timing of surgical treatment in valvular heart disease. Ann Intern Med 1981;94:498 –504. 5. Eckberg DL, Gault JH, Bouchard RL, Karliner JS, Ross J Jr. Mechanics of left ventricular contraction in chronic severe mitral regurgitation. Circulation 1973;47:1252–1259.
1014
The American Journal of Cardiology (www.AJConline.org)
6. Starling MR, Kirsh MM, Montgomery DG, Gross MD. Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction. J Am Coll Cardiol 1993; 22:239 –250. 7. Crawford MH, Souchek J, Oprian CA, Miller DC, Rahimtoola S, Giacomini JC, Sethi G, Hammermeister KE. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation 1990;81:1173–1181. 8. Tei C, Ling LH, Hodge DO, Bailey KR, Oh JK, Rodeheffer RJ, Tajik AJ, Seward JB. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function—a study in normals and dilated cardiomyopathy. J Cardiol 1995;26:357–366. 9. Borow KM, Green LH, Mann T, Sloss LJ, Braunwald E, Collins JJ, Cohn L, Grossman W. End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med 1980;68:655– 663. 10. Carabello BA, Nolan SP, McGuire LB. Assessment of preoperative left ventricular function in patients with mitral regurgitation: value of the end-systolic wall stress-end-systolic volume ratio. Circulation 1981;64:1212–1217. 11. Zile MR, Gaasch WH, Carroll JD, Levine HJ. Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol 1984;3: 235–242. 12. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, Frye RL. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol 1994;24:1536 –1543. 13. Leung DY, Griffin BP, Stewart WJ, Cosgrove DM III, Thomas JD, Marwick TH. Left ventricular function after valve repair for chronic
14.
15.
16. 17. 18.
19.
20. 21.
mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996;28:1198 –1205. Lee R, Hanekom L, Marwick TH, Leano R, Wahi S. Prediction of subclinical left ventricular dysfunction with strain rate imaging in patients with asymptomatic severe mitral regurgitation. Am J Cardiol 2004;94:1333–1337. Kim YJ, Jones M, Greenberg NL, Popovic ZB, Sitges M, Bauer F, Thomas JD, Shiota T. Evaluation of left ventricular contractile function using noninvasively determined single-beat end-systolic elastance in mitral regurgitation: experimental validation and clinical application. J Am Soc Echocardiogr 2007;20:1086 –1092. Moller JE, Poulsen SH, Egstrup K. Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance. J Am Soc Echocardiogr 1999;12:1065–1072. Pai RG, Bansal RC, Shah PM. Doppler-derived rate of left ventricular pressure rise. Its correlation with the postoperative left ventricular function in mitral regurgitation. Circulation 1990;82:514 –520. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, Scott C, Schaff HV, Tajik AJ. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875– 883. Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, Schemper M, Maurer G, Baumgartner H. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006;113:2238 – 2244. Delahaye JP, Gare JP, Viguier E, Delahaye F, De Gevigney G, Milon H. Natural history of severe mitral regurgitation. Eur Heart J 1991; 12(suppl B):S5–S9. Al-Mukhaini M, Argentin S, Morin JF, Benny C, Cusson D, Huynh T. Myocardial performance index as predictor of adverse outcomes following mitral valve surgery. Eur J Echocardiogr 2003;4:128 –134.